ARTICLE

ONLINE FIRST
Effect of Hospital-Based Comprehensive Care
Clinic on Health Costs for Medicaid-Insured
Medically Complex Children
Patrick H. Casey, MD; Robert E. Lyle, MD; Tommy M. Bird, MS; James M. Robbins, PhD; Dennis Z. Kuo, MD, MHS;
Carrie Brown, MD; Arti Lal, MD; Aline Tanios, MD; Katherine Burns, MD

Objective: To evaluate the effect on all state Medicaid
costs of a children’s hospital-based multidisciplinary clinic
that provides comprehensive and coordinated care for
medically complex children.
Design: Before-after intervention study. Patients’ health
care costs for up to 1 year before enrollment in the clinic
were compared with patients’ health care costs for up to
1 year after enrollment in the clinic. Patients were en-
rolled in our study from August 2006 to May 2008.
Setting: Tertiary care children’s hospital in a rural state.
Participants: A total of 225 medically complex children
who had at least 2 chronic medical conditions and who were
followed up by at least 2 pediatric subspecialists.
Intervention: Multidisciplinary teams ensure that each
patient receives all the necessary medical, nutritional, and
developmental care and that there is improved coordi-
nation of care with primary care providers, subspecial-
ists, hospitalists, and community-based services.
Main Outcome Measures: Using Arkansas Medicaid
claims data, we examined the medical costs for all out-
patient, inpatient, emergency department, and prescrip-
tion drug claims. Costs were calculated on a per month
per patient basis and summarized for annual costs.
Results: The mean annual cost per patient per month
decreased by $1766 for inpatient care (P⬍.001) and by
$6.00 for emergency department care (P ⬍ .001). Al-
though the cost per patient per month for outpatient
claims (P⬍ .05) and prescriptions (P⬍ .001) increased,
the overall cost to Medicaid per patient per month de-
creased by $1179 (P ⬍ .001).
Conclusions: This hospital-based multidisciplinary clinic
resulted in a significant decrease in total Medicaid costs
for medically complex children.
Arch Pediatr Adolesc Med. 2011;165(5):392-398.
Published online February 7, 2011.
doi:10.1001/archpediatrics.2011.5

Author Affiliations:
Department of Pediatrics,
University of Arkansas for
Medical Sciences, Arkansas
Children’s Hospital, Little Rock.
I
MPROVEMENTS IN SURGICAL, GEN-
eral medical, and intensive care
have increased the survival of low-
birth-weight children born pre-
term with various congenital
anomalies. As a result, an increasing num-
ber of children with multiple chronic con-
ditions now live at home.1-6 Many such
children have an associated chronic neu-
rodevelopmental disability and are in need
of assistance with special medical equip-
ment (such as tracheostomy and gastros-
tomy tubes).7-9 These medically complex
children (MCC) have the most medically
complex conditions of children with spe-
cial health care needs (CSHCN).10,11 Al-
though CSHCN experience more hospital
admissions and outpatient visits com-
pared with healthy children,12 MCC may re-
quire even more hospitalizations and phy-
sician visits. Although the health care needs
of CSHCN often are not met,13-15 MCC have
an even higher number of unmet needs,
both within the health care system and with
community-based services.10,16,17
Primary care providers often acknowl-
edge a lack of comfort, time, and re-
sources in treating and coordinating the
care of MCC.18,19 Tertiary care subspecial-
ists provide quality, organ system–
focused care; however, the coordination
and the integration of an overall care plan
are not typical, and communication among
specialists and primary care providers is
sometimes not optimal. As a result, care
may be ineffective or duplicated, poten-
tially resulting in increased resource uti-
lization and poorer outcomes. Some chil-
dren’s hospitals have begun to develop
special programs dedicated to better serv-
ing MCC. Some programs provide conti-
nuity of care during hospitalizations,20,21
whereas others assist in care coordina-
tion in ambulatory settings.22,23

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 Recognizing the increasing number of MCC and their
need for comprehensive and coordinated care, Arkan-
sas Children’s Hospital (ACH) initiated a medical home
program for MCC.24 It was hypothesized that this pro-
gram would result in fewer acute hospitalizations and
emergency department visits, resulting in reduced over-
all costs of medical care.
METHODS
SETTING
Arkansas is a primarily rural state with approximately 2.8 mil-
lion citizens and 699 000 children 18 years of age or younger.
Arkansas Children’s Hospital is the only tertiary care hospital
in the state that provides subspecialty care and surgical care
for children. The vast majority of children in Arkansas requir-
ing subspecialty care receive their care at ACH.
INTERVENTION
The goals of the medical home program are to ensure that each
child receives all the necessary medical, nutritional, and de-
velopmental and/or therapeutic care and to improve the coor-
dination of care for all physicians and other providers at ACH
and in the communities. Arkansas Medicaid requires all Med-
icaid-eligible children to have a primary care provider to act as
a referral gatekeeper. The children continue seeing their com-
munity-based primary care provider as well as all needed pe-
diatric subspecialists. The program is outpatient-based, with
coordination with inpatient services during hospitalization. The
clinic staff includes pediatricians (neonatologist, developmen-
tal pediatricians, hospitalists, and general pediatricians), nurses,
nutritionists, social workers, speech pathologists, and child psy-
chologists. At least 1 person from each discipline is present for
each clinic visit; this way, the continuity of care by the clinic
team is ensured. The frequency of visits is determined by clini-
cal need. Each patient is assigned a nurse coordinator who meets
with the child and family in the clinic. The nurse is available
for telephone consultation during daytime hours to assist with
concerns of any type, including appointment coordination, clini-
cal decision making, and acute care issues. The clinic team en-
sures that the needed community-based services are provided
and that communications with these programs and the pri-
mary care providers occur via letter, e-mail, and/or telephone.
SUBJECTS
Children eligible for enrollment in the medical home program
are high utilizers of services at ACH who have at least 2 seri-
ous chronic conditions and were followed up by at least 2 pe-
diatric subspecialists. Many are born with extremely low birth
weight (or with congenital anomalies and/or syndromes), with
chronic neurodevelopmental disability, and/or are dependent
on special medical equipment (such as gastrostomy tubes). Eli-
gible children, who live throughout the state, are referred by
their primary care provider or by a pediatric subspecialist with
approval by the primary care provider. All children in our study
were eligible for Medicaid and were continuously enrolled from
the outset of the new program beginning in August 2006 and
ending May 2008. Excluded from the analyses were (1) chil-
dren who had been previously followed by the codirectors of
the medical home program (R.E.L. and P.H.C.) in their prior
existing clinics; (2) children 90 days of age or younger, to ex-
clude hospitalizations in neonatal intensive care units (which
would have inflated the hospital costs prior to the initial Medi-
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cal Home Clinic visit); and (3) children who died. There were
281 children enrolled in the clinic who met the study criteria.
Matching to Medicaid claims data was accomplished for 225
children, who make up the final sample for the analyses. Match-
ing was not successful for 56 children because of inconsisten-
cies in the child’s name or Medicaid identification number be-
tween ACH clinical records and Medicaid files.
DATA
The University of Arkansas for Medical Sciences institutional
review board reviewed and approved the research protocol. Our
study is a retrospective cohort study of eligible enrollees in the
Medical Home Clinic. Demographic and clinical data for our
study came from hospital medical records. Demographic data
include patients’ sex, race/ethnicity, and age at first clinic visit.
Clinical data include number and type of complex chronic con-
ditions. All cost and resource utilization data came from link-
ing hospital data to Arkansas Medicaid data. Medicaid utiliza-
tion and cost data were obtained statewide for all (not just ACH)
inpatient stays, outpatient claims (including physician visits and
therapy treatment), emergency department visits, and prescrip-
tion drugs. Utilization data were obtained for up to 12 months
before and after the index clinic visit.
ANALYSES
Because of the varying ages of the enrolled children, the ex-
clusion criteria based on age of child at enrollment, and the stag-
gering of enrollment over time, the number of children eli-
gible for inclusion in our study varied across the different time
frames (ie, before and after the first clinic visit). For example,
because the minimum age at enrollment was 90 days, children
enrolled at 15 months of age or younger could not have 12
months of preenrollment data. Similarly, children enrolled less
than 12 months before the end of the data collection could not
have 12 months of postenrollment data. To account for the vary-
ing number of subjects across months, all cost data were stan-
dardized on a per patient per month (PPPM) basis. Because the
distribution of the PPPM utilization data was significantly posi-
tively skewed, multivariable analyses were conducted using a
generalized linear model with a gamma distribution and a log
link. Multivariable analyses before and after enrollment relied
on predicted pre- and post-PPPM cost values adjusted for sex,
race/ethnicity, and age at index clinic visit. To gain a more de-
tailed understanding of utilization patterns before and after en-
rollment in the clinic, a piecewise generalized linear model was
used. Our piecewise model allowed for different slopes, or uti-
lization trends, as well as different intercepts for pre- and posten-
rollment periods. All analysis was conducted using Stata/MP
version 11.1 statistical software (StataCorp LP, College Sta-
tion, Texas).
RESULTS
Demographic and selected clinical characteristics of the
225 study subjects are presented in Table 1. Sixty-two
percent were male children, and 50% were white. The
mean (SD) age at enrollment was 19.4 (21.3) months,
and the median age was 13 months. The oldest child at
enrollment was 158 months.
Before enrollment, the mean (SD) number of hospi-
talizations PPPM was 0.1 (0.3), and the mean (SD) num-
ber of outpatient claims PPPM was 10.3 (7.4). Of the 225
children enrolled in our study, 152 (67%) were born pre-
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Table 1. Demographic and Clinical Characteristics of and
Preenrollment Utilization Data on 225 Medical Home
Clinic Patients
Characteristic or Data
Sex
M 140 (62)
F 85 (38)
Race
White
Black
Missing or other
Diagnoses
Premature
Bronchopulmonary dysplasia
Hydrocephaly
Cerebral palsy related to brain injury or anomaly
Seizures
Syndrome and/or anomalies
Congenital heart disease
Developmentally delayed
Type of medical equipment needed
Gastrostomy tube
Tracheostomy tube
Ventriculoperitoneal shunt
Preenrollment health care utilization
Age in months at first clinic visit
Mean (SD)
Median (range)
Hospitalizations per month, No.
Mean (SD)
Median (range)
Emergency department visits per month, No.
Mean (SD)
Median (range)
Outpatient claims per month, No.
Mean (SD)
Median (range)
term, 84 (37%) had bronchopulmonary dysplasia as di-
agnosed by the neonatologist, 127 (56%) received a gas-
trostomy tube, 17 (7%) received a tracheostomy tube, 75
(33%) had cerebral palsy related to brain injury or
anomaly, 161 (72%) were clinically determined to be de-
velopmentally delayed, and 91 (40%) had a recognized
syndrome or congenital anomaly. Six children had a tra-
cheoesophageal fistula, 10 had a diaphragmatic hernia,
6 had gastroschisis and/or omphalocele, 6 had Down syn-
drome, 11 had a cleft palate and/or lip, 8 had CHARGE
syndrome and/or VATER association, and 5 had velo-
cardio-facial and/or DiGeorge syndrome. Children with
the following syndromes also visited the Medical Home
Clinic: Angelman, Pierre Robin, Prader-Willi, Klinefel-
ter, Williams, and Kabuki syndromes.
The actual and adjusted costs to Medicaid PPPM for
12 months before and 12 months after the initial Medi-
cal Home Clinic visit are shown in Table 2. The ad-
justed cost of outpatient claims increased by $53 PPPM
($1729 before vs $1782 after; P⬍ .05), and the adjusted
cost of prescription drugs increased by $60 ($329 be-
fore vs $389 after; P⬍.001). The adjusted cost PPPM for
inpatient care decreased by $1766 ($2995 before vs $1229
after; P⬍.001), and the adjusted cost of emergency de-
partment visits decreased by $6 ($50 before vs $44 af-
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ter; P ⬍ .001). The overall adjusted costs PPPM to Med-
icaid decreased by $1179 for the year after the initial visit
($4703 before vs $3524 after; P ⬍.001).
Trends in the actual and adjusted overall costs to Med-
icaid PPPM during the year before the first clinic visit
No. (%)
and during the year after the first clinic visit are shown
in Figure 1. The sample size available for each month
is depicted on the x-axis. There was a gradual increase
in overall cost PPPM during the year before the first clinic
113 (50) visit, from near $4200 to near $5000. There was a gradual
49 (22) decrease in overall costs PPPM after the first clinic visit,
63 (28) ending near $3000.
Trends in the actual and adjusted costs to Medicaid
152 (67)
PPPM for the year before the first clinic visit and the year
84 (37)
14 (6) after the first clinic visit are shown in Figure 2. There
75 (33) was a gradual increase in inpatient cost PPPM from near
43 (19) $2200 to near $3700 in the year before the first clinic visit.
91 (40) There was a striking decrease in inpatient cost PPPM af-
32 (14) ter the first visit, ending near $600.
161 (72)
The adjusted number of inpatient stays PPPM de-
127 (56)
creased from 0.15 for the year before the first clinic visit
17 (7) to 0.11 for the year after the first clinic visit (P ⬍.001).
26 (12) For the year before the first clinic visit, patients had a
9.7% chance of hospitalization, and for the year after the
clinic visit, patients had a 7.4% chance of hospitaliza-
19.4 (21.3) tion (P ⬍.001). The length of stay during a hospitaliza-
13 (3-158)
tion PPPM decreased from 2.25 days for the year before
0.1 (0.3) the first clinic visit to 1.25 days for the year after the first
0 (0-3) clinic visit (P ⬍ .001). The mean length of stay per hos-
pitalization was reduced from 14.5 days preenrollment
0.1 (0.5) to 10 days postenrollment (P ⬍.01).
0 (0-6) Trends in the actual and adjusted outpatient claims
costs to Medicaid PPPM for the year before and the year
10.3 (7.4)
9 (1-33) after the first Medical Home Clinic visit are shown in
Figure 3. Although there was a slight decrease in out-
patient cost PPPM during the year before the first clinic
visit, there was a slight increase in cost PPPM for the year
after the first visit. Adjusted outpatient cost PPPM in-
creased by $53 ($1729 before vs $1782 after; P⬍.05).
The number of outpatient claims PPPM increased from
9.4 for the year before the first clinic visit to 10.3 for the
year after the first clinic visit (P⬍ .001). The number of
emergency department visits PPPM decreased from 0.18
for the year before the first clinic visit to 0.16 for the year
after the first clinic visit (P ⬍.001).
COMMENT
The clinical intervention of the ACH medical home pro-
gram resulted in significantly fewer inpatient stays PPPM
with significantly shorter lengths of hospital stay. This
resulted in an annual savings of $1766 PPPM. The num-
ber of outpatient claims per child per month increased,
but emergency department contacts decreased for the year
after the first clinic visit compared with the year before
the first clinic visit. The aggregate cost savings for Ar-
kansas Medicaid, including the costs mentioned earlier
as well as medications and other related expenses, was
$1179 PPPM for the year after the first clinic visit.
Based on these total cost data, the predicted
adjusted annual cost for a theoretical group of 225
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394
 Table 2. Actual and Adjusted Medicaid Costs for 12 Months Before and 12 Months After Entry Into the Medical Home Clinic

Bivariate Analysis Multivariable Analysis a

Cost, $, per Patient
per Month Before After Difference (95% CI) Before After Difference (95% CI)
Overall 4744 3503 −1241 (−2057 to −425) 4703 3524 −1179 (−1232 to −1126)
Inpatient 2868 1298 −1570 (−2416 to −724) 2995 1229 −1766 (−1813 to −1720)
Outpatient 1652 1797 145 (21-269) 1729 1782 53 (8-97)
Emergency department 46 44 −2 (−14 to 10) 50 44 −6 (−7 to −5)
Prescription 306 374 68 (23-112) 329 389 60 (56-64)

Abbreviation: CI, confidence interval.

a The results of multivariable analysis were adjusted for sex, race/ethnicity, and age at entry into Medical Home Clinic by use of a generalized linear model.

8000

7000

6000
PPPM Overall Cost, $

5000

4000

3000

2000

1000

0
)

)
05

12

16

23

30

39

53

68

80

95

12

25

25

25

25

25

25

25

25

25

09

89

75

63
=1

=1

=1

=1

=1

=1

=1

=1

=1

=1

=2

=2

=2

=2

=2

=2

=2

=2

=2

=2

=2

=1

=1

=1
(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n
12

11

10

10

11

12
Before Clinic Enrollment After Clinic Enrollment

Figure 1. Actual and adjusted per patient per month (PPPM) overall cost to Medicaid for 12 months before and 12 months after clinic enrollment. PPPM cost
values were adjusted for sex, race/ethnicity, and age at clinic enrollment by use of a generalized linear model. The number for each month represents the number
of children (ie, the sample size per month).

7000

6000

5000
PPPM Inpatient Cost, $

4000

3000

2000

1000

0
)

)
05

12

16

23

30

39

53

68

80

95

12

25

25

25

25

25

25

25

25

25

09

89

75

63
=1

=1

=1

=1

=1

=1

=1

=1

=1

=1

=2

=2

=2

=2

=2

=2

=2

=2

=2

=2

=2

=1

=1

=1
(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n

(n
12

11

10

10

11

12

Before Clinic Enrollment After Clinic Enrollment

Figure 2. Actual and adjusted per patient per month (PPPM) inpatient cost to Medicaid for 12 months before and 12 months after clinic enrollment. PPPM cost
values were adjusted for sex, race/ethnicity, and age at clinic enrollment by use of a generalized linear model. The number for each month represents the number
of children (ie, the sample size per month).

MCC before enrollment in the Medical Home Clinic the Medical Home Clinic would be $9 514 800. This
would be $12 698 100. The predicted adjusted annual would result in an annual cost saving of $3 183 300 for
cost for a theoretic group of MCC after enrollment in the theoretical 225 patients, with savings of $14 148

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 3000

PPPM Outpatient Cost, $ 2500

2000

1500

1000

500

0
5)

2)

6)

3)

0)

9)

3)

8)

0)

5)

2)

5)

5)

5)

5)

5)

5)

5)

5)

5)

9)

9)

5)

3)
10

11

11

12

13

13

15

16

18

19

21

22

22

22

22

22

22

22

22

22

20

18

17

16
=

=
(n

(n

(n

(n

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(n

(n

(n

(n

(n

(n

(n

(n
12

11

10

10

11

12
Before Clinic Enrollment After Clinic Enrollment

Figure 3. Actual and adjusted per patient per month (PPPM) outpatient cost to Medicaid for 12 months before and 12 months after clinic enrollment. PPPM cost
values were adjusted for sex, race/ethnicity, and age at clinic enrollment by use of a generalized linear model. The number for each month represents the number
of children (ie, the sample size per month).

per patient per year, at least for the first year after the care programs resulted in significantly shorter hospital
initial clinic visit. stays,30,35 more outpatient visits,30 and decreased hospi-
To our knowledge, this is the first examination of the tal charges compared with national data.35 Emergency de-
aggregate cost impact of a comprehensive care model for partment visits of MCC decreased after the integration
MCC. The American Academy of Pediatrics and other medi- of a comprehensive care coordination program in a resi-
cal groups have endorsed comprehensive, coordinated care dent education clinic36 and after the onset of an emer-
provided in a family-centered medical home.25,26 Emerg- gency department–based coordination program that pro-
ing evidence is supportive of the medical home concept, vided 24-hour access to nurse coordinators.37
but the data are mostly limited to children with a single Gordon et al22 described the results before and after
chronic condition like asthma or epilepsy, with short- the implementation of a program that best resembled our
term outcomes such as family function, satisfaction with ACH medical home program. They enrolled children with
care, and timeliness of care.27 Studies of programs that tar- complex chronic conditions that involved 3 or more or-
geted both children with single chronic conditions and MCC gan systems requiring the care of at least 5 pediatric sub-
and that provided more comprehensive coordinated care specialists. Pediatric nurse case managers provided no
have demonstrated improved parent satisfaction with direct care but served as coordinators for all medical- and
care,28,29 decreased family needs and caregiver strain,29 im- community-based needs. The hospital-based physicians
proved quality of life for parents,30 improved child adjust- saw program patients in the emergency department, some-
ment,31 and receipt of more community services.32 times during clinic visits, and they also participated in
Other studies have evaluated the number of inpa- the care of hospitalized children. This program resulted
tient, outpatient, and/or emergency department visits and in a significant decrease per patient in the number of in-
their associated costs as an outcome of interventions tar- patient admissions and days in the hospital, as well as a
geting children with special health care needs. Broyles significant increase in outpatient clinic and emergency
et al33 examined the benefits of comprehensive care pro- department visits. In aggregate, these changes resulted
vided to very low birth weight infants in a randomized in a decrease of payment of $10.7 million to the hospi-
controlled trial. The comprehensive care group had sig- tal. Our results extend these findings by utilizing all ag-
nificantly more clinic visits and telephone conversa- gregate state Medicaid costs, not just costs generated by
tions, with fewer life-threatening illnesses, intensive care one hospital.
admissions, and days in intensive care compared with the Because we did not feel ethically comfortable design-
routine care group. Beckmezian et al21 compared the care ing a randomized controlled intervention trial or using
provided by a typical subspecialty/house staff team with a wait-list control design with these MCC, we used a be-
a staff-only hospitalist team. The hospitalist team dem- fore-after intervention study design to assess health costs.
onstrated hospital stays that were shorter by 2.7 days with Although we attempted to adhere to the high standards
29% lower costs. of this type of research design, our conclusions may be
Much of the remaining research in this field has uti- limited. For example, the natural course of disease might
lized the before-after intervention design. A comprehen- result in improved clinical status with age, thus result-
sive care program that served 4-year-old CSHCN, few of ing in decreased clinical encounters of all types over time.
whom were medically complex, found no difference be- However, we found an upward trend of hospitalizations
fore and after enrollment in the number of hospitaliza- and associated costs that decreased immediately after the
tions or in associated costs.34 Expanded comprehensive implementation of our medical home program (ie, Medi-

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 cal Home Clinic). In addition, we controlled for age at
first clinic visit in an attempt to address the concern of
maturing out of a serious condition. The number of pa-
tients available for analyses each month varied depend-
ing on when they were first enrolled in our clinic and
on how long they were followed up after the first clinic
visit. We were not able to match 56 of our subjects to
Medicaid data because of inconsistencies in identifiers
in the 2 data sets. There is no reason to think that these
children differed significantly from those included in the
analyses, because all our patients were consecutively en-
rolled and met our enrollment criteria for medical com-
plexity. In addition, they did not differ in demographic
characteristics. Our results may not apply to children who
are not publically insured, and our model examines only
a single program at one institution. Although it is fea-
sible that other hospital- or Medicaid-supported initia-
tives occurring concomitant with ours might have influ-
enced our results, we were aware of no such program.
Finally, we do not have data that document changes in
patient health status.
Our report has several strengths. Our use of Arkan-
sas Medicaid data allowed us to determine all clinical con-
tacts and associated costs, not just those occurring in our
hospital. We were thus able to determine that decreased
utilization and cost to our hospital were not offset by in-
creased costs at other provider sites. Our analytical plan
is unique in that we were able to evaluate the PPPM ex-
perience in each of our outcomes for the year before and
the year after our initial clinical contact.
We acknowledge that our use of the term “medical
home” differs from that used by the Academy of Pediat-
rics and others, which implies care provided in the pri-
mary care setting.25,26 We propose that the notion of a
medical home be expanded for this subpopulation of very
complex children who often challenge the time and ca-
pacity of primary care providers. The medical home is
not a building or location; rather, it is the concept of com-
prehensive, coordinated, and accessible care that all chil-
dren deserve. The expanded multidisciplinary team of-
fers these MCC the opportunity to have the coordinated
and comprehensive care often not available when their
care is provided in a primary care setting supported by
consultation with tertiary care providers.
In summary, the ACH medical home program re-
sulted in significant decrease in total Medicaid costs for
the MCC cared for in our clinic. The savings resulted pri-
marily from a decrease in inpatient costs, by decreasing
both the number of hospitalizations and the length of stay.
Future research is needed to determine whether the co-
ordinated and comprehensive care resulted in better pa-
tient quality of life and health status, as well as improve-
ment in the quality of life, mental health, satisfaction with
care, and general well-being of their care providers.
Accepted for Publication: December 7, 2010.
Published Online: February 7, 2011. doi:10.1001
/archpediatrics.2011.5
Correspondence: Patrick H. Casey, MD, Department of
Pediatrics, University of Arkansas for Medical Sciences,
Arkansas Children’s Hospital, 1 Children’s Way, Rm 512-
26, Little Rock, AR 72202 (caseypatrickh@uams.edu).
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Author Contributions: Study concept and design: Casey,
Lyle, Bird, Robbins, Kuo, and Tanios. Acquisition of data:
Casey, Lyle, Bird, Lal, and Burns. Analysis and interpre-
tation of data: Casey, Lyle, Bird, Robbins, Kuo, Brown,
and Burns. Drafting of the manuscript: Casey, Lyle, Rob-
bins, and Kuo. Critical revision of the manuscript for im-
portant intellectual content: Casey, Lyle, Bird, Robbins, Kuo,
Brown, Lal, Tanios, and Burns. Statistical analysis: Bird.
Obtained funding: Robbins. Administrative, technical, and
material support: Casey, Lyle, Kuo, Brown, and Lal. Study
supervision: Casey, Lyle, and Robbins.
Financial Disclosure: None reported.
Funding/Support: Support has been provided in part by
the Arkansas Biosciences Institute, the major research
component of the Tobacco Settlement Proceeds Act of
2000.
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