Hispanic children with special health care needs from Spanish-language households.

OBJECTIVES: We examined the specific health care needs of Hispanic children with special health care needs (CSHCN) from Spanish-language households, and we compared the needs for children in this group to those for Hispanic and non-Hispanic white CSHCN from English-language households. METHODS: We estimated the prevalence of parent-reported health care needs, health conditions, and functional characteristics by using data from the 2001 and 2005-2006 National Survey of Children With Special Health Care Needs. We used bivariate and multivariate methods to describe the relationship between ethnicity, language, and the demographic, socioeconomic, and health characteristics of CSHCN. RESULTS: Between 2001 and 2005-2006, the prevalence of special health care needs increased significantly among Hispanic and non-Hispanic white children from English-language households but not among Hispanic children from Spanish-language households. In 2005-2006, Hispanic children from Spanish-language households were only one-third as likely as other children to be identified as CSHCN. Relative to both Hispanic and non-Hispanic white CSHCN from English-language households, Hispanic CSHCN from Spanish-language households had a higher prevalence of several developmentally related conditions and of functional difficulties related to gross and fine motor coordination, self-care, speech, and communication but had a lower prevalence of attention-deficit/hyperactivity disorder. Lower use of prescription medications was significantly associated with Hispanic ethnicity (regardless of household language) even after we controlled for demographic and socioeconomic differences. CONCLUSIONS: Hispanic CSHCN from Spanish-language households are distinct from other CSHCN, and stratifying the Hispanic population by using primary household language can reveal important differences in the health and functioning characteristics of Hispanic CSHCN.

An analysis of the association between parental acculturation and children's medication use.

OBJECTIVES: We examined how Hispanic children, with stratification according to language to approximate acculturation, differed with respect to sociodemographic characteristics and medication use. We also examined how different factors were associated with the use of different classes of prescription medications. METHODS: We used data from the 2004 Medical Expenditure Panel Survey linked to the National Health Interview Survey. Independent variables were grouped as predisposing characteristics, enabling factors, perceived need, and evaluated need. Multivariate logistic regression was used to assess the impact of independent variables on the outcomes of overall and specific types of medication use. RESULTS: Hispanic, Spanish-interviewed children were less likely to have a usual source of care than were Hispanic, English-interviewed subjects. Both groups had lower odds of using any prescription medication, compared with white children, which was explained largely by having a usual source of care. The lower use of psychiatric medications in the Spanish-interviewed group was not explained by the independent variables, whereas the difference in the use of antibiotics was. CONCLUSIONS: There are differences between Hispanic children according to acculturation, and acculturation affects prescription medication use. These findings may be used to address more specifically the needs of Hispanic children, particularly mental health needs.

Consistently inconsistent: a snapshot of across- and within-state disparities in the prevalence of childhood overweight and obesity.

BACKGROUND: The epidemic of childhood overweight and obesity is characterized by known disparities. Less is known about how these disparities vary across and within the state in which a child lives. OBJECTIVE: To examine the magnitude and patterns of across- and within-state differences in the prevalence of childhood overweight and obesity according to children's insurance type (public versus private), household income level, race (non-Hispanic black versus non-Hispanic white), and ethnicity (Hispanic versus non-Hispanic). METHODS: State-level overweight and obesity prevalence rates for children aged 10-17 were calculated by using data from the 2003 National Survey of Children's Health. Statistical significance of across-state variation was assessed. Disparity ratios assessed within-state equity according to children's insurance type, income, race, and ethnicity. State ranks on overall prevalence and ranks on disparity indices were correlated and regression models were fit to examine within-state consistency, state-level clustering effects and whether the effect of child characteristics varied across key population subgroups. RESULTS: Prevalence of childhood overweight and obesity varied significantly across states. A total of 31 states had a prevalence lower than the national rate of 30.6% (14 statistically significant), and 20 had higher rates (9 statistically significant). Within-state disparity indices ranged from a low of 1.0 (no disparity) to a high of 3.44 (nearly 3.5 times higher). Correlations between state ranks on overall prevalence and their ranks on disparity indices were not significant for the insurance type, income, or race disparity groups examined. A modest state-clustering effect was found. Compared with non-Hispanic white children, the effect of lower household income and lower household education level education were significantly less for non-Hispanic black and Hispanic children, who were more likely to be overweight or obese regardless of these other factors. CONCLUSIONS: Disparities in the prevalence of childhood overweight and obesity vary significantly both within and across states. Patterns of variation are inconsistent within states, highlighting the need for states to undertake state- and population-specific analyses and interventions to address the epidemic.

Differentiating subgroups of children with special health care needs by health status and complexity of health care needs.

OBJECTIVES: Our objective is to use the Children with Special Health Care Needs (CSHCN) Screener to identify subgroups of CSHCN differentiated by health status and complexity of need. METHODS: Data are from the National Survey of Children with Special Health Care Needs, 2001 and the National Survey of Children's Health, 2003 (conducted by the Maternal and Child Health Bureau and the National Center for Health Statistics); and the 2001 and 2002 Medical Expenditure Panel Survey, conducted by the Agency for Healthcare Research and Quality. A broad array of variables measuring health status, complexity of need, and related issues are examined by subgroupings of CSHCN. RESULTS: Relative to other CSHCN, CSHCN with functional limitations or who qualify on more CSHCN Screener items have poorer health status and more complex health care needs. They more often experience a variety of health issues; their insurance is more often inadequate; the impact of their conditions on their families is higher; and their medical costs are higher. CONCLUSION: In the absence of information on specific conditions, health status, or complexity of need, the CSHCN Screener alone can be used to create useful analytic subgroups that differ on these dimensions. The proposed subgroups, based on the type or number of CSHCN screening criteria, differentiate CSHCN by health status and complexity of health care needs, and also show differences in the impact of their conditions on their families, costs of their medical care, and prevalence of various health problems.

What is the prevalence of children with special health care needs? Toward an understanding of variations in findings and methods across three national surveys.

OBJECTIVES: To compare and consider sources of variation in the prevalence and characteristics of children with special health care needs (CSHCN) identified using the CSHCN Screener across the 2001 National Survey of Children with Special Health Care Needs (NS-CSHCN), the 2003 National Survey of Children's Health (NSCH) and the 2001-2004 Medical Expenditures Panel Surveys (MEPS). METHODS: For each survey, national prevalence rates and the demographic, health and health need characteristics of CSHCN age 0-17 years were estimated and compared. The stability of CSHCN state prevalence rankings between the NS-CSHCN and NSCH was assessed. Logistic regression analysis produced adjusted odds of identification for subgroups of children. CSHCN Screener sampling and administration were profiled across eight methodology parameters for each survey. RESULTS: Compared to the NS-CSHCN (12.8%), CSHCN prevalence for children age 0-17 years was 4.8 points higher for the NSCH (17.6%) and 6.0-6.5 points higher across the four 2001-2004 MEPS datasets (18.8-19.3%). The adjusted probability of identification by child's demographic characteristics was stable across all datasets as were state prevalence rankings between the NS-CSHCN and the NSCH. CSHCN identified through the NS-CSHCN were slightly more likely to meet more than one CSHCN Screener criteria, to meet the "above routine need or use of services" criterion and to miss two or more weeks of school due to illness compared to the NSCH, suggesting that CSHCN with less complex and/or serious health consequences may not have been as likely to be identified through the NS-CSHCN. CSHCN prevalence did not change significantly between 2001 and 2004 MEPS, although some off-setting increases or decreases in the proportion of CSHCN meeting specific CSHCN Screener criteria occurred and reflects trends toward increased prescription medication use in children. CONCLUSIONS: When CSHCN Screener administration methods remained similar across years (2001-2004 MEPS), CSHCN prevalence rates were stable. When methods varied between surveys, CSHCN prevalence rates differed. These differences suggest that prevalence is best expressed as a range, rather than as a point estimate. However, once identified, characteristics and health needs of CSHCN were stable across surveys evaluated, each of which has unique strengths for purposes of policy and research.

An evaluation of the linguistic and cultural validity of the Spanish language version of the children with special health care needs screener.

OBJECTIVES: The 2001 National Survey of Children with Special Health Care Needs (CSHCN) used the CSHCN Screener, a 5-item survey based tool, to identify children with special health care needs. The prevalence of special health care needs for Hispanic children was lower than that reported for all other ethnic and racial groups, with the exception of Asian children. To better understand the reasons for the lower prevalence rate, this study examined variations in CSHCN prevalence for Hispanic children according to whether parents responded to the National Survey of CSHCN screening interview in Spanish or English. The Spanish translation of the CSHCN Screener was further evaluated through a series of face-to-face interviews with parents with limited English proficiency (LEP). METHODS: The 2001 National Survey of CSHCN screened 372,174 children ages 0-17 years for special health care needs. Bivariate and multivariate analyses were conducted to examine the effects of interview language on the CSHCN prevalence rates for Hispanic children (n = 47,371). Using a standardized protocol, cognitive interviews were conducted in Spanish with 19 LEP parents to elicit their comprehension of and reactions to the screening questions. RESULTS: When parents were interviewed in English, 11.7% of Hispanic children were identified as CSHCN. When parents were interviewed in Spanish, 5.1% of Hispanic children were identified as CSHCN. Lower prevalence of the need for or use of prescription medications for chronic conditions made the largest contribution to the observed difference in CSHCN prevalence. Cognitive interviews with parents did not identify any linguistic or cultural deficiencies in the Spanish translation of the CSHCN Screener. Parents did express disinclination toward sharing details of their children's health in the context of a typical telephone survey.

Using existing population-based data sets to measure the American Academy of Pediatrics definition of medical home for all children and children with special health care needs.

OBJECTIVE: National health goals include ensuring that all children have a medical home. Historically, medical home has been determined by the presence of a usual or primary source of care, such as a pediatrician or a family physician. More recent definitions expand on this simplistic notion of medical home. A definition of medical home set forth by the American Academy of Pediatrics (AAP) includes 7 dimensions and 37 discrete concepts for determining the presence of a medical home for a child. Standardized methods to operationalize these definitions for purposes of national, state, health plan, or medical practice level reporting on the presence of medical homes for children are essential to assessing and improving health care system performance in this area. The objective of this study was to identify methods to measure the presence of medical homes for all children and for children with special health care needs (CSHCN) using existing population-based data sets. METHODS: Methods were developed for using existing population-based data sets to assess the presence of medical homes, as defined by the AAP, for children with and without special health care needs. Data sets evaluated included the National Survey of Children With Special Health Care Needs, the National Medical Expenditures Panel Survey, the Consumer Assessment of Health Plans Study Child Survey (CAHPS), and the Consumer Assessment of Health Plans Study Child Survey--Children With Chronic Conditions (CAHPS-CCC2.0H). Alternative methods for constructing measures using existing data were compared and results used to inform the design of a new method for use in the upcoming National Survey of Children's Health. Data from CAHPS-CCC2.0H are used to illustrate measurement options and variations in the overall presence of medical homes for children across managed health care plans as well as to evaluate in which areas of the AAP definition of medical home improvements may be most needed for all CSHCN. RESULTS: Existing surveys vary in their coverage of concepts included in the AAP definition of medical home and, therefore, in their capacity to evaluate medical home for children with and without special health care needs. Using data from CAHPS-CCC2.0H, the overall proportion of children who were enrolled in managed care health plans and met criteria for having a medical home varied from 43.9% to 74% depending on the specific scoring method selected for these items. Wide variations across health plans were observed and were most prominent in the areas of "accessible care" and "comprehensive care." Performance was uniformly poorest in the area of "coordinated care" and for CSHCN. Although children with a personal doctor or nurse were more likely to meet the AAP criteria for having a medical home, simply having a personal doctor or nurse was not highly predictive of whether a child experienced the other core qualities of a medical home (positive predictive value: .50; negative predictive value: .59). CONCLUSIONS: Despite differences across existing surveys and gaps in concepts represented, we believe that the AAP definition of medical home can be well represented by the small subset of concepts represented in the National Survey of Children With Special Health Care Needs and the CAHPS-CCC2.0H. A less comprehensive yet still worthwhile measure is possible using the Medical Expenditures Panel Survey. The varying degrees of empirical evidence and consensus for each of the AAP definition domains for medical home suggest the need for constructing measures that also vary in terms of criteria for determining that a child does or does not have a medical home. In addition to a simple "yes or no," or rate-based, measure, a continuous medical "homeness" score that places a child or group of children on a continuum of medical "homeness" is also valuable. Findings indicate that health plans have an important role to play in ensuring medical homes for children in addition to medical practices and those who set policies that guide the design and delivery of health care for children. Oven. Overall, using existing population-based data, a measure of medical home that is aligned with the AAP definition is feasible to include in the annual National Healthcare Quality Report, in state reports on the quality of Medicaid, State Children's Health Insurance Program, and Title V programs as well as to evaluate performance on the Healthy People 2010 objectives and the President's New Freedom Initiative.

Comparison of the children with special health care needs screener to the questionnaire for identifying children with chronic conditions--revised.

BACKGROUND: The Children with Special Health Care Needs (CSHCN) Screener is an instrument to identify CSHCN, one that is based on parent-reported consequences experienced by children with ongoing health conditions. Information about how this instrument compares to other methods for identifying CSHCN is important for current and future uses of the CSHCN Screener. RESEARCH OBJECTIVES: The goal of this study was to assess the level of agreement between the CSHCN Screener and the Questionnaire for Identifying Children With Chronic Conditions--Revised (QuICCC-R) and to describe the characteristics of children in whom these methods do not agree. METHODS: The CSHCN Screener and the QuICCC-R were administered to 2 samples: a random sample of parents of children under age 18 years through the first pretest of the National CSHCN Survey (n = 2420) and a random sample of children under age 14 years enrolled in a managed care health plan (n = 497). Information on specific conditions and needs for health services were collected for children identified by one or both instruments in the national sample. Data from the administrative data-based Clinical Risk Groups (CRGs) were collected for all children in the health plan sample. The proportions of children identified with the CSHCN Screener and the QuICCC-R were compared, the level of agreement between these 2 methods was assessed, and the health service needs of children identified by the QuICCC-R but not the CSHCN Screener were evaluated. RESULTS: In both study samples, the CSHCN Screener agreed with the QuICCC-R approximately 9 out of 10 times on whether or not a child was identified as having a special health care need. Compared to the CSHCN Screener, the QuICCC-R identified an additional 7.6% and 8.5% of children as having special health care needs in the national and health plan samples, respectively. Compared to children identified by the QuICCC-R only, the odds were 12 times greater that children identified by both the CSHCN Screener and the QuICCC-R needed health care services, 6 times greater that parents named a specific chronic health condition, and 9 times greater that children were identified with a chronic condition using the CRG algorithm. Study design and purposeful differences in question design or content account for most cases in which children are not identified by the CSHCN Screener but are identified using the QuICCC-R. CONCLUSIONS: The brief CSHCN Screener exhibits a high level of agreement with the longer QuICCC-R instrument. Whereas nearly all children identified by the CSHCN Screener are also identified by the QuICCC-R, the QuICCC-R classifies a higher proportion of children as having special health care needs.

Identifying children with special health care needs: development and evaluation of a short screening instrument.

BACKGROUND: Public agencies, health care plans, providers, and consumer organizations share the need to monitor the health care needs and quality of care for children with special health care needs (CSHCN). Doing so requires a definition of CSHCN and a precise methodology for operationalizing that definition. RESEARCH OBJECTIVES: The purpose of this study was to develop an efficient and flexible consequence-based screening instrument that identifies CSHCN across populations with rates commensurate with other studies of CSHCN. METHODS: The CSHCN Screener was developed using the federal Maternal and Child Health Bureau (MCHB) definition of CSHCN and building on the conceptual and empirical properties of the Questionnaire for Identifying Children with Chronic Conditions (QuICCC) and other consequence-based models for identifying CSHCN. The CSHCN Screener was administered to 3 samples: a national sample of households with children (n = 17985), children enrolled in Medicaid managed care health plans (n = 3894), and children receiving Supplemental Security Income (SSI) benefits in Washington State (n = 1550). The efficiency, impact of further item reduction, and flexibility of administration mode were evaluated. Rates and expected variation in rates across demographic groups of children positively identified by one or more of the 5 CSHCN Screener item sequences in each sample were examined and multinomial logistic regression analysis were conducted to evaluate the effect of child characteristics in predicting positive identification. RESULTS: The CSHCN Screener took approximately 1 minute per child to administer by telephone and 2.1 minutes per household. During self-administration, over 98% of respondents completed each of the 5 CSHCN Screener item sequences, and respondents accurately followed each of the item skip patterns 94% of the time. Mailed surveys and telephone-administered surveys led to similar rates of positive identification in the same sample. Two Screener items would have identified 80%-90% of children positively identified as CSHCN across the study samples, although using only 2 items eliminates some children with more complex health needs. Rates of children identified by the CSHCN Screener varied according to age, sex, race/ethnicity, health status, and utilization of health services. CONCLUSIONS: Results of this study indicate that the CSHCN Screener requires minimal time to administer, is acceptable for use as both an interview-based and self-administered survey, and that rates of children positively identified by the CSHCN Screener vary according to child demographic, health, and health care-need characteristics. The CSHCN Screener provides a comprehensive yet parsimonious and flexible method for identifying CSHCN, making it more feasible than existing measures for standardized use across public agencies, health care plans, and other users.