The Relationship between Complementary and Alternative Medicine and Conventional Health Care Access,

Expenditures and Experiences among US Children

Presented by:

Christina Bethell, PhD, MBA, MPH

The Child and Adolescent Health Measurement Initiative

Oregon Health & Science University

Co-Authors: Paul Newacheck, Narangerel Gombojav, PhD,

Scott Stumbo, MA, Cambria Wilhelm, MPH, John Neff, MD

Christina BethellHas documented that he/she has no financial relationships to disclose or Conflicts of Interest (COIs) to resolve.

Objectives

1. To calculate the prevalence of CAM use among children with chronic conditions and special health care needs

2. To assess the association between CAM use and conventional medical care (CM): utilization, access, parent's experience and CM expenditures

3. To evaluate the validity and sufficiency of available population based data to address priority integrative pediatrics health services research questions

Data:

1. 2007 National Health Interview Survey (NHIS, n=9,417),

2. Linked file of the 2007 NHIS to the 2008 Medical Expenditure Panel Survey (MEPS) (n=2,411)

3. 2009/10 National Survey of Children with Special Health Care Needs (NS-CSHCN; n=40,243).

Primary Methods:

Construct variables and estimate weighted prevalence

Multivariate analyses were used to calculate adjusted odds ratios (AOR), controlling for children's chronic condition and special needs status and demographic characteristics.

Data and Methods

Data SetsSample Children in Data Files

Sample Child File n=9,417

Family File n=29,915

Person File n=75,764

Sample Adult and

Adult CAM File n=23,393

2007 NHIS Child CAM

File n=9,417

2008 MEPS Full Year

Consolidated Data File n=9,538 (children)

2007 NHIS 2008 MEPS (Panel 13)

Linked File n=2,411

Office-Based

Medical Provider

Visits File

Medical Conditions

File

Prescribed Medicines

File

2007 NHIS 2008 MEPS

At the family level

Panel 13 child sample: n=5,769

CAM Modalities Asked in 2007 NHIS Child CAM Supplement

• 39 specific types of CAM modalities used in past 12 months (use of vitamins/minerals and herbal supplements in past 30 days among those who used in past 12 months)

- DURING THE PAST 12 MONTHS, did [fill: S.C. name] see a provider or practitioner for any of the following therapies? Please say yes or no to each. Acupuncture?

Two CAM Groupings 1. Products; Practices; Practitioners

2. Alternative Medical Systems; Biologically-Based Approaches; Manipulative and Body-Based Therapies; Mind-Body Therapies

Vitamins/minerals (VM) use43.3% past 12 months

84.6% in past 30 days

.

CAM Use Definitions Previous Studies and Current Study

0%

10%

20%

30%

40%

50% 47.5%

12.9% 12.0% 11.7%

n=4140 34.6 M

n=1133 9.4 M

n=1055 8.7 M

n=1025 8.5 M

*support group meeting and stress management class

4.2% to treat specific conditions84.6% any of

59 conditions59.3% any of 46

chronic conditions

CAM Item in NS-CSHCN: Single Item

C3Q15: Alternative health care can include acupuncture, chiropractic care, relaxation therapies, herbal supplements, and others. Some therapies involve seeing a practitioner, while others can be done on your own.[During the past 12 months/ Since [his/her] birth], did [S.C.] use any type of alternative health care or treatment?

• Health Status:– CAM use is associated with the complexity and

intensity of children’s health conditions. o CSHCN twice as likely to use CAM as non-

CSHCN.o There is a linear relationship between the

number of reported conditions and number of CAM modalities used.

ResultsWho uses CAM?

• Utilization of Conventional Medical Care:– Higher use of conventional medical care and

higher expenditures was associated with CAM use– CAM use is more common among children who

had difficulties accessing conventional medical care.

– Children with complex condition whose parents are less satisfied with quality of conventional care (e.g. doctors’ communication) are more likely to use CAM.

ResultsWho uses CAM?

Meta Data Issue #1Results:

Prevalence of Children Using CAM

• NHIS All Child Rate: The estimated prevalence of CAM* use among US children: 12.9% (9.4 million). 45.4% used 2+ types of CAM

• NHIS CSHCN Rate: 22.5% (40% CAM users are CSHCN using CAHMI constructed CSHCN variable); AOR: 2.25

• MEPS CSHCN Rate: 23.6% (CSHCN Screener)

• NS-CSHCN Rate: 10.8%*includes vitamins/minerals used to treat specific conditions in past 30 days

0%

2%

4%

6%

8%

10%

12%

4.1%

11.3%

6.1%

10.5%

4.1%

8.2%

6.9%

9.2%

CSHCN in NHIS - Algorithm (n=1981) CSHCN in MEPS - Screener (NHIS/MEPS) n=414

Results: CAM Types Used Among CSHCN, 2007 NHIS and NHIS/MEPS

RSE>30

p=0.13

Common acute conditions (n=5,577)

Sensory problems (n=527)

Respiratory/pulmonary conditions (n=2,450)

Gastroenterology problems (n=2,444)

Dermatological problems (n=1.439)

Developmental problems (n=771)

Neurological problems (n=670)

Other conditions (n=1,228)

Emotional/mental/behavioral conditions (n=1,307)

Pain-related conditions (n=1,084)

0% 5% 10% 15% 20% 25% 30%

14.9%

16.1%

18.0%

18.4%

19.8%

21.8%

22.0%

23.8%

24.2%

24.9%12.1%

16.5%

13.1%

7.7%

8.7%

16.1%

27.9%

26.4%

5.9%

61.7%

NOTE: Percent shown in the boxes (white) are prevalence of conditions

CAM Use, by Condition Type Child Experiences, 2007 NHIS

CAM Use Among Children with Conditions Who Met the CSHCN Algorithm Criteria

7.6%

1 2 3 4 1 2 3 40%

20%

40% 36.8%

21.1%

35.0%

9.6%

26.5%22.5%

11.1% 10.5%

1- CSHCN with back or neck pain (n=163)2- CSHCN without back or neck pain (n=1812)3- Non-CSHCN with back or neck pain (n=148)4 -Non-CSHCN without back or neck pain (n=7284)

1 - CSHCN with ADD/ADHD (n=449)2- CSHCN without ADD/ADHD (n=1364)3 - Non-CSHCN with ADD/ADHD (n=91)4 - Non-CSHCN without ADD/ADHD (n=6319)

AOR: 2.53*

AOR: 4.13*

Ref

AOR: 2.26*

AOR: 0.92

*statistically significantAORs adjusted for age, sex, race/ethnicity, income and region

Ref

AOR: 2.50*

AOR: 4.65*

Of 4.6% of children with back or neck pain 53.1% met the CSHCN algorithm criteria

Of 7.2% of children with ADD/ADHD 84.8% met the CSHCN algorithm criteria

Alternative Medical System/Energy Healing

(2.7% n=231)

Biologically-based therapies

(5.8% n=492)

Manipulative and body-based therapies (3.7% n=301)

Mind-body therapies (4.7%

n=403)

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

AOR: 1.66*

AOR: 2.21*

AOR: 3.31* AOR: 2.41*

AO

R:1

.80*

AO

R: 2

.42*

AO

R: 1

.68*

AO

R: 4

.76*

AOR: 1.37*

AOR: 2.29*

AOR: 2.33*

AOR: 2.56*

AOR: 1.97*

AOR: 2.29*

AOR: 1.71*

AOR: 2.21*

AOR: 2.10*

AOR: 2.13*AOR: 2.40*

AOR: 2.41*

AOR: 1.88*AOR: 2.49*

AOR: 2.64*

AOR: 3.02*

Pain-related conditions (12.1%) EMB Conditions (16.5%)Gastroenterology problems (27.9%) Respiratory and pulmonary conditions (26.4%)Common acute conditions (61.7%) Developmental problems (8.7%)Neurological problems (7.7%)

Variations In Use By Type of Health Conditions Child Experience

CAM use, by condition status

0% 5% 10% 15% 20% 25%

9.6%

15.6%

18.2%

22.5%

23.6%

Activity limitations caused by chronic condition (n=643)CSHCN (n=1,981)At least 1 chronic condition (n=4,902)Any condition from all 59 conditions (n=6,947)Non-chronic condition ONLY (n=2,045)

22.1%

53.1%

75.3%

29.5%

CAM use, by number of conditions

0% 5% 10% 15% 20% 25% 30%

4.4%

7.3%

12.2%

11.7%

16.7%

26.4%

6 or more conditions (n=1,542) 4-5 conditions (n=1,571) 3 conditions (n=1,132) 2 conditions (n=1,261) 1 condition (n=1,441) No conditions asked in the survey (n=2,470)

18.0%

17.3%

12.1%

13.2%

14.7%

24.7%

Relationship of CAM Use and Health Status Complexity, 2007 NHIS

7.6%

NOTE: Percent shown in the boxes (white) are prevalence of conditions

AOR: 2.52 (2.09-.3.03)

CAM Use Among CSHCN with Functional Difficulties1 and Conditions2, 2009/10 NS-CSHCN

4 or more conditions

3 conditions

2 conditions

1 condition

No condition

4 or more difficulties

3 difficulties

2 difficulties

1 difficulty

No difficulties

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

17.1%

12.0%

10.2%

8.3%

8.2%

13.8%

9.7%

9.5%

7.5%

5.9%8.8%

19.2%

14.1%

12.3%

45.6%

12.3%

30.6%

28.0%

12.5%

16.6%

Ref

AOR: 1.55*

AOR: 2.73*

AOR: 1.55*

AOR: 1.55*

Ref

1 from the list of 14 functional difficulties asked about 2 from the list of 20 conditions asked about

*statistically significant MOTE: AORs are adjusted for age, sex, race/ethnicity, income, insurance type

CAM Use, by CSHCN Screener Qualifying Criteria, 2009/10 NS-CSHCN

0%

4%

8%

12%

16%

20%

8.2%

14.0%

15.4%

8.5%

9.7%

12.9%

18.5%

23.5% 51.6%%

20.5% 13.8% 14.0%

AOR: 1.21*

AOR: 1.70*

AOR: 2.36*

Ref: 1.00

AOR: 1.43*

3.9.3% 31.8%

Ref: 1.00

AOR: 2.79*

*statistically significant

NOTE: AORs are adjusted for age, sex, race/ethnicity, income and insurance type

CAM Use and Average Number of Office-Based Visits (Adjusted and Unadjusted), NHIS/MEPS

All children Among CSHCN*

Statistics Mean 95% CIs p value1 Mean 95% CIs p value1

Among children with office-based visits to physician and/or non-physician

CAM users 6.0 4.8-7.2<.0001

10.4 7.3-13.4.03Non-CAM users

3.6 3.1-4.2 6.6 4.3-8.9

Among children who had office-based visits to physician

CAM users 4.0 3.4-4.7.001

5.3 3.8-6.8.04

Non-CAM users2.8 2.5-3.1 4.5 3.5-5.5

*CSHCN reported in MEPS1 independent samples t testNOTE: Office-based non-physician visits include visits to chiropractors, nurse or nurse practitioner, optometrists, physician assistants, and physical or occupational therapist

Number of CAM Modalities Used, by Number of Medical Care Visits, 2007 NHIS

0-1 v

isits

(33.8

%)

2-3 v

isits

(35.4

%)

4-5 v

isits

(15.4

%)

6-7 v

isits

(6.6%

)

8 or m

ore v

isits

(8...

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

70.9% 71.9% 71.1%55.2% 58.3%

18.1% 16.2% 18.2%

21.2% 16.7%

11.0%* 11.9% 10.7%23.6% 25.0%

1 CAM modality (67.4%) 2 CAM modalities (17.8%)3 or more CAM modalities (14.7%)

*RSE=30

Results: Quality of CareDid Not Meet MCHB CSHCN Core Outcomes,

by CAM use, 2009/10 NS-CSHCN

0%

10%

20%

30%

40%

50%

60%

70%

37.0%

63.0%

50.2%

20.7%

49.9%

60.5%

28.8%

56.3%

38.1%

21.5%

33.1%

59.9%

Used CAM Did not use CAM

p<.0001

p<.0001 p<.0001

p=.5

p=.9A

OR

: 1

.64*

AO

R:

1.58

*

AO

R:

1.78

*

AO

R:

1.05

AO

R:

2.26

*

AO

R:

1.25

Ref

Ref

Ref

Ref

Ref

Ref

*statistically significant

Types of CAM Modalities Used and Health Care Access Problems (Unmet Needs or Delay), by

Condition Type, 2007 NHIS

Condition typeHealth care access

problem

Alternative Medical System/Energy healing1 2.7%

(n=231)

Biologically-based therapies2

5.8% (n=492)

Manipulative and body-based therapies3

3.7% (n=301)

Mind-body therapies4 4.7%

(n=403)

All children (n=9417)

Of those with a problem (n=1572)

4.0%AOR: 1.48

10.1%AOR: 1.87 *

5.3%AOR: 1.52*

7.9%AOR: 1.80*

Of those without a problem (n=7845)

2.5% Ref

5.0% Ref

3.4%Ref

4.0% Ref

Among CSHCN (n=1981)

Of those with a problem 5.4%AOR: 1.64

13.0%AOR: 1.45

7.7%AOR 1.78 *

13.5%AOR: 1.87*

Of those without a problem

3.6%Ref

10.6%Ref

5.4%Ref

9.2%Ref

Among children with at least 1 chronic condition (n=4902)

Of those with a problem 4.5%AOR: 1.58*

12.6% AOR: 1.90*

6.7% AOR: 1.75*

10.3%AOR: 2.16*

Of those without a problem

3.1% Ref

7.5%Ref

4.5%Ref

5.9%Ref

Among, children with emotional, behavioral or mental condition (n=1307)

Of those with a problem 6.2%AOR: 2.29*

14.6%AOR: 1.59*

9.1%AOR: 1.97*

17.1%AOR: 1.61*

Of those without a problem 3.1%

Ref10.8%

Ref5.2% Ref

12.7%Ref

Among children with pain-related condition (n=1084)

Of those with a problem 4.8%AOR: 1.17

14.8%AOR: 1.69*

9.7%AOR: 0.89

13.6%AOR: 1.73*

Of those without a problem

3.7%Ref:

10.2%Ref

10.4%Ref

8.9%Ref

Among children with gastroenterology problem (n=2444)

Of those with a problem 4.6%AOR: 1.47

14.6%AOR: 2.01*

7.3%AOR: 1.23

11.1%AOR: 1.81*

Of those without a problem

3.1%Ref

7.9%Ref

5.9%Ref

6.9%Ref

CAM Use and Quality of Care, 2009/10 NS-CSHCN

0%

3%

6%

9%

12%

15%

18%16.0%

11.1%

6.6%

Level of satisfaction with Dr to Dr communication

Big or small problem

No problem Referrals are not needed

0%

3%

6%

9%

12%

15%

18% 17.1%

13.2%

9.1%

Problems Getting Referrals

Ref

Ref

AO

R:

1.60

*

AO

R:

1.52

*

CAM Use and Health Care Expenditures (Adjusted), NHIS/MEPS

Total health care expenditures

CAM use statusChildren with expenditures

Mean after adjusting covariates, among children with expenditures

n % Mean CI p

All children (n=2411) 2014 84.5% $1,537 1,468-1,606 NA

CAM users (n=294) 263 91.0% $2,354 2,146-2,563<.0001

Non-CAM users (n=2094) 1734 83.6% $1,382 1,319-1,445

Note: Expenditures were estimated by 2-part model adjusting age, sex, race/ethnicity, income, region and CSHCN status (NHIS)

Out-of-pocked health care expenditures

CAM use statusChildren with expenditures

Mean after adjusting covariates, among children with expenditures

n % Mean CI p

All children (n=2411) 1411 64.8% $354 332-377 NA

CAM users (n=294) 204 75.4% $476 420-532<.0001

Non-CAM users (n=2094) 1194 63.1% $329 307-351

• Sample size in linked NHIS/MEPS File – Prevents further analaysis of link between use of CAM in time 1 and

conventional medical care in time 2 (suggestive findings)

• Methods for NHIS CAM Supplement Regarding “condition/reason for using CAM

Key Limitations

Utilization of Emergency Room in Matched and Future Year of CAM Use, NHIS and NHIS/MEPS

Series10%

5%

10%

15%

20%

25%

30%

35%

40%

19.0%22.5% 22.6%

32.4%

15.1%18.8%

13.8%

37.9%

Among CAM users Among non-CAM users

n=23 n=98 n=13 n=38 n=10 n=60 n=4 n=19

Among CSHCN, 29.5% n=51

Among non-CSHCN, 18.3% n=70

Among CSHCN identified in both surveys, n=237

RSE>30

Of those who had one or more ER visit (reported in NHIS n=1889), % of children who also reported ER visit in future year (reported in MEPS among children who linked to NHIS n=341) 21.9% n=121

p=0.5

p=0.3

p=0.6?

p=0.02?

All children, 21.9% n=121

Hospitalization, by CAM Use and CSHCN Status, NHIS/MEPS

MEPS – NHIS/MEPS

Survey Item/Description

Data used to construct the inpatient utilization variable for newborns were edited to exclude stays where the newborn left the hospital on the same day as the mother. However, if the newborn was discharged at a later date than the mother was discharged, then the discharge was considered a separate stay for the newborn when constructing the utilization variable.

All children 2.3% (n=57)

Among CSHCN (MEPS)4.0% (n=15)

Among CAM users 2.4%* (n=12) 2.5%* (n=3)

Among non-CAM users 2.3% (n=45) 3.9%* (n=12)

Results: CAM use and Most Common Conditions Reported in Sample Child Core and Child CAM

SupplementAmong children who experienced the condition ever1 or in past 12 months (Sample Child Core), % children used CAM

Conditions parents named as a reason to use CAM (Child CAM Supplement)

Conditions n % Conditions n %

Congenital heart disease1 8 45.8% Other - specify 104 10.0%

Anxiety or stress (4-17 yrs) 199 36.6% Back or neck pain 88 8.2%

Back or neck pain 120 36.0% Head or chest cold 72 8.1%

Mental retardation1 16 34.4% Anxiety or stress 55 5.7%

Urinary tract infection 36 34.0% Musculoskeletal 52 5.1%

Depression (4-17 yrs) 74 33.0% Anemia 35 3.4%

Autism1 20 32.8% ADD/ADHD 38 3.2%

Fatigue or lack of energy 103 32.6% Asthma 20 2.0%

Other heart condition1 23 31.9% Sore throat other than strep. 18 2.0%

Insomnia (3-17 yrs) 128 31.8% Insomnia 20 1.9%

Severe acne 68 31.6% Depression 21 1.7%

Anemia 36 31.1% Allergies other than hay fever/resp., food/skin allergies, eczema

13 1.6%** RSE>30

NOTE: Conditions with RSE>30 not listed

Additional Slides

Total Health Care Expenditures (Unadjusted), by Type of Services,

NHIS/MEPS

Types of servicesAll children CAM users Non-CAM users

n %1 Mean2 n %1 Mean2 n %1 Mean2

Total expenditures 2,014 84.5% 1,889 263 91.0% 3,101* 1,734 83.6% 1,633

Total office-based visits 1,647 70.6% 647 216 73.4% 1,429 1,419 70.4% 506

Office-based visits to physicians

1,551 65.6% 528 203 68.1% 1,118 1,338 65.4% 421

Office-based visits to non-physicians

414 21.3% 511 76 28.2% 1,020 335 20.3% 389

Total hospital outpatient visits

149 6.8% 1,533 21 6.4% 2,835 127 6.9% 1,328

Total emergency room visits 322 12.9% 932 44 12.1% 879 275 13.1% 941

Inpatient hospital stays 55 2.2% 12,095 11 2.1% 17,348 44 2.2% 11,230

Prescription medication 1,122 50.0% 439 150 56.1% 1,063 967 49.4% 315

1 % of children with expenditures 2 mean expenditures among children with expenditure*excluding extreme outlier

Identification of CSHCN in NHIS: NHIS Items Met CSHCN Screener Qualifying Criteria

CSHCN Screener Consequences Qualifying CriteriaScreener criterion: Child currently needs or uses medicine prescribed by a doctor, other than vitamins

- Child has problem for which he/she has taken prescription medications regularly for three or more months- *Reports unmet need for prescription medications, past 12 months, due to cost

Screener criterion: Child needs or uses more medical care, mental health or educational services than is usual- Has impairment or health problem that requires use of special equipment, including brace, wheelchair, or hearing aid (excluding eyeglasses and special shoes)

- Ten or more visits to a health professional, past 12 months- One or more overnight hospital stays other than for birth, past 12 months- Any homecare visits, past 12 months- Currently receives special education or early intervention services- *Reports unmet need for medical care, past 12 months, due to cost

Screener criterion: Child is limited or prevented in any way in his/her ability to do the things most children of the same age can do

- *Limited in any way: play (0-4 years), walk without using a special equipment, difficulty remembering, and other - Needs help from others with any personal care needs, age 3-17- Has mobility impairment that has lasted or is expected to last 12 months- Blind or not able to see- Hearing ability without hearing aid——has a lot of trouble

Screener criterion: Child needs or gets special therapy, such as physical, occupational, or speech therapy- Family member has seen/talked to a physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist in past 12 months concerning the health of the child

Screener criterion: Child has emotional, developmental, or behavioral problem for which he/she needs treatment or counseling- Family member has seen/talked to mental health professional (psychiatrist, psychologist, psychiatric nurse, clinical social worker) in past 12 months concerning the health of the child-*Reports unmet need for mental health counseling, past 12 months, due to cost

- *Children who saw a general doctor (a doctor in general practice, pediatrics, family medicine, internal medicine) because of emotional or behavioral problems they may have during past 12 months

Table x

Identification of CSHCN in NHIS: Conditions

A. Parents told by a HEALTH PROFESSIONAL that child had ever or in past 12 months

n

ADD/ADHD (2-17 years) 540Mental retardation 54Other developmental delay 274Downs syndrome 12Cerebral palsy (Q3 and 4) 11Muscular dystrophy 3Cystic fibrosis 1Sickle cell anemia 17Autism 58Diabetes 17Arthritis 10Congenital heart disease 120Other heart conditionAsthma, with episode in past 12 months 485Depression (4-17) 195Learning disability (3-17) 557Cancer 8Neurological problem 108Phobia or fears (4-17) 204Gum disease 44Lung or breathing problem (other than asthma) 318

Summary Measures of Health ConditionsComprehensive list (A, B, or C): Any listed conditions diagnosed by health professional, conditions reported by parents, VLBW

Limited list (A or C): Any of listed health conditions diagnosed by health professional, VLBW

B. Parents reported that child had any of listed conditions in past 12 months

n

Any seizure 67Respiratory allergy 856Eczema or skin allergy 856Food or digestive allergy 378Anemia 121Severe headaches/migraines (3-17) 396Frequent diarrhea or colitis 155Hay fever 9313 or more ear infection 484Recurring headache (non-migraine) (3-17) 329Stuttering or stammering (3-17) 119Other allergies 451Anxiety or stress (4-17) 588Sever acne 246Other chronic pain 110Fatigue or lack of energy 293

C. Other condition**Child very low birth weight <1500g

(VLBW)*, <2 years old 35

Table x

Adjusted Odds Ratios for Identification of CSHCN by Demographic Characteristics

Characteristics 2007 NHIS (Algorithm)

2008 MEPS (Screener)

2007 NSCH (Screener)

Age

0-5 years 1.00 1.00 1.00 6-11 years 1.51 (1.28 - 1.78) 2.38 (1.95 - 2.91) 2.19 (1.96 - 2.44) 12-17 years 1.83 (1.56 - 2.14) 2.54 (2.04 - 3.15) 2.30 (2.06 - 2.56)Sex       Male 1.33 (1.17 - 1.51) 1.71 (1.45 - 2.01) 1.51 (1.40 - 1.64) Female 1.00 1.00 1.00Race/ethnicity       White, non-Hispanic 1.00 1.00 1.00 Hispanic 0.59 (0.50 - 0.70) 0.47 (0.38 - 0.58) 0.59 (0.50 - 0.69) Black, non-Hispanic 0.69 (0.57 - 0.85) 0.86 (0.71 - 1.05) 0.94 (0.84 - 1.06) Multi/other, non-Hispanic 0.71 (0.55 - 0.92) 0.76 (0.58 - 1.01) 0.76 (0.66 - 0.88)Family income     0-99% FPL 1.65 (1.33 - 2.05) 1.08 (0.82 - 1.43) 1.41 (1.24 - 1.60) 100-199% FPL 1.23 (1.03 - 1.47) 1.04 (0.84 - 1.29) 1.14 (1.02 - 1.28) 200-399% FPL 1.05 (0.90 - 1.22) 0.93 (0.74 - 1.16) 1.02 (0.92 - 1.13) 400% FPL or above 1.00 1.00 1.00

Characteristics2007 NHIS(n=9417)CSHCN 1

(algorithm)

2008 MEPS(n=9538)CSHCN 2

(Screener)

NHIS/MEPS (n=2411)CSHCN 2

(Screener)

Prevalence 22.1% (n=1981) 18.4% (n=1541) 21.4% (n=414)

Age

0-5 years 25.5% (n=516) 18.9% (n=314) 20.3% (n=97)6-11 years 33.5% (n=638) 39.5% (n=631) 33.7% (n=148)

12-17 years 41.0% (n=827) 41.6% (n=596) 46.0% (n=169)

Race

White, non-Hips 62.8% (n=1052) 64.5% (n=657) 66.6% (n=179)

Hispanic 16.7% (n=484) 13.4% (n=360) 13.4% (n=101)

Black non-Hips 13.8% (n=300) 15.0% (n=394) 12.7% (n=95)

Insurance

Public insurance 31.5% (n=638) 31.9% (n=706) 27.6% (n=168)

Private insurance 61.0% (n=1163) 64.2% (n=769) 67.1 %(n=224)

Health/

Health Care

Missed 11+ school days (5-17) 10.1% (n=177) 10.3% (n=114) 12.4% (n=35)

2 or more ER visit 14.7% (n=294) 5.2% (n=86) 4.0% (n=19)

Children with expenditures NA 96.2% (n=1467) 97.3% (n=402)

Characteristics of CSHCN Identified in the Study Data Files

1 Source of characteristics: NHIS, Sample child weights 2 Source of characteristics: MEPS, MEPS Person weights

Table x

CSHCN Identified by the Algorithm in NHIS versus CSHCN Identified by the Screener in MEPS

Of CSHCN identified by the Screener in MEPS (Panel 13), 59.9%2 (n=237) have been identified as CSHCN by the algorithm in NHIS. (55.9%1 of CSHCN identified by the algorithm met the Screener criteria)

38.8%1 (n=440) of all child CAM users met criteria for having a special health care needs by the NHIS algorithm (42.0%2 n=122 in the NHIS/MEPS).

30.4%2 (n=76) of all child CAM users met criteria for having a special health care needs by the CSHCN Screener in NHIS/MEPS.

Are they same children?

Among CAM users, of children met CSHCN Screener criteria 81.2%2 (n=59) have been identified as CSHCN by the algorithm (59.5%2 of CSHCN identified by the algorithm met the Screener criteria)

Note: 1 weighted by sample child weights 2 weighted by the linked file adjusted weights

Meta Data Issue #1CAM Use and Conditions

Conditions asked in Sample Child Core and Child CAM Supplement

• Validity, utility and repetitiveness of asking about conditions the child experiences and for which the child uses CAM.

87.1%

Among CAM users – CAHMI definition,

% who named a condition* in Sample Child Core

91.7% n=1033

n=1,133

Conditions Reported in Sample Child Core and Child CAM Supplement

87.1%

Among CAM users – CAHMI definition,

% who named a condition* in Child CAM Supplement

Non-CAM users CAM users

49.5%, n=500

n=1,133

*from 59 conditions asked about

Among CAM users, % of Children Whose Parents Named Same Condition in Sample Child Core and

Child CAM Supplement

Conditions

Used CAM

Named the condition as a resaon to use CAM

Parents named the

same condition

Among conditions in Sample Child, % named the condition

in Child CAM

Among conditions in Child CAM , %

named the condition in Sample Child

n n n % %

Autism n=58 20 6 6 28.6%* 100.%

Depression n=195 74 21 21 28.2% 100%

Food/digestive allergies n=378 87 11 11 12.4%* 100.%

Non-strep. sore throat n=2808 514 18 17 4.2% 98.0%

Insomnia n=387 128 20 20 14.9% 89.9%

ADD/ADHD n=540 133 38 33 23.7% 88.4%

Head or chest cold n=4456 708 72 65 11.3% 88.3%

Allergies other than hay fever/resp., food/skin allergies, eczema n=451

91 12 11 16.6%* 86.9%

Anxiety or stress n=538 199 55 48 26.1% 85.2%

Anemia n=121 36 35 25 69.0% 66.8%

Asthma n=485 86 20 13 16.9% 63.9%

Back or neck pain n=311 120 88 50 42.0% 52.7% *RSE>30

Table x

CAM Use for Children with Back or Neck Pain

9.6%

Among CAM users (n=1,133), % of children experience back or neck pain (n=120)

8.2%

Among CAM users (n=1,133), % of parents named back or neck pain as a reason to use CAM (n=88)

47.3%

Among children whose parents named back or neck pain as a rea-son to use CAM (Child CAM), % of parents DID NOT name back or neck pain in Sample Child Core (n=38)

Prevalence of back or neck

pain 3.4% n=311

Sam

ple

Chi

ld C

ore

Chi

ld C

AM

Su

pple

men

t

Among children who experience

back or neck pain, 36.0% of children used CAM (n=120)

Among CAM users (n=1,133), % of children experience depression (n=74)

1.7%

Among CAM users (n=1,133), % of children whose parents depression as a reason to use CAM (n=21)

Prevalence of depression

3.0% n=195

Chi

ld C

AM

Su

pple

men

t

100.0%

Among children whose parents named depression as a reason to use CAM (Child CAM), % of children named depression in Sample Child Core (n=21)

6.9%

CAM Use for Children with Depression

Among children who experience

depression, 33.0% of

children used CAM (n=74)

Sam

ple

Chi

ld C

ore

2007 NHIS and 2008 MEPS Linked File

• Linkage of NHIS and MEPS datasets result in 2,411 cases of data which is insufficient to validity explore the many condition specific patterns and associations critical to better understanding the need for and impact of integrative medicine in children.

 

ResultsPrevalence of CAM Use*, by CSHCN status

CSHCN Non-CSHCN

22.5%

10.1%

23.6%

9.8%

21.8%

12.4%0.108

2007 NHIS NHIS/MEPS (CSHCN status in NHIS)

NHIS/MEPS (CSHCN status in MEPS) 2009/10 NS-CSHCN (CSHCN only)**

AOR: 2.52 (2.09-.3.03)

CSHCN Prevalence: 2007 NHIS: 22.1% n=19812008 MEPS: 18.4% n=1541NHIS/MEPS (CSHCN in NHIS): 23.0% n=518NHIS/MEPS (CSHCN in MEPS): 21.4% n=4142009/10 NS-CSHCN: 15.1% n=40242

*includes vitamins/minerals used for therapeutic purposes in past 30 days**CAM use is a singe itemAOR adjusted by age, sex, race/ethnicity, income and region (2007 NHIS, Reference category: Non-CSHCN)

All children0%

5%

10%

15%

20%

25%

12.9% 13.0%

2007 NHIS (n=9417)

NHIS/MEPS (n=2411)

n=1133 n=294

• Children’s health status is more complex among CAM users compared to non-CAM users

Children’s Health Status and Conditions Child Experiences

7.6%

0%

20%

40%

60%

80%

100% 91.7%

75.0%

38.8%

13.9% 16.7%

73.1%

50.0%

19.7%

6.7%

23.1%

CAM Users, n=1,133Non-CAM users, n=8,104

Table RF 6

p=<.0001

p=<.0001

p=<.0001

p=<.0001p=<.0001

CAM users experience all types of conditions than those who did not use CAM.

Type of Conditions Child Experiences, 2007 NHIS, by CAM Use Status

7.6%

Pain (n

=1,084

)

EMB (n

=1,307

)1

Gastro

enter

olog

y (n=

2,444

)

Respi

rator

y (n=

2,450

)

Common

acut

e (n

=5,577

)

Develo

pmen

tal (n

=771)

Neuro

logi

cal (

n=67

0)

Senso

ry (

n=52

7)

Dermato

logi

cal (

n=1,4

39)

Other

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

25.2

%

32.2

% 43.6

%

40.2

%

77.5

%

16.3

%

14.2

%

7.5%

26.4

%

25.7

%

10.3

%

14.0

%

25.7

%

24.5

%

59.5

%

7.6%

6.7%

5.7%

14.6

%

11.3

%

CAM Users, n=1,133Non-CAM users, n=8104

Table RF 6

Type of CAM Used, by Type of Condition Child Experiences,

All Children, 2007 NHIS

Alternative Medical System/Energy Healing

(2.7% n=231)

Biologically-based therapies

(5.8% n=492)

Manipulative and body-based therapies (3.7% n=301)

Mind-body therapies (4.7%

n=403)

0%

2%

4%

6%

8%

10%

12%

14%

16%

4.0%

11.7

%

10.2

%

10.4

%

4.0%

11.9

%

6.4%

14.0

%

3.4%

9.5%

6.3%

7.8%

4.1%

9.5%

5.6%

8.0%

3.1%

7.5%

4.6%

6.0%

3.7%

12.9

%

5.7%

11.3

%

4.8%

11.6

%

5.8%

10.6

%

Pain-related conditions (12.1%) EMB Conditions (16.5%)Gastroenterology problems (27.9%) Respiratory and pulmonary conditions (26.4%)Common acute conditions (61.7%) Developmental problems (8.7%)Neurological problems (7.7%)

8 or More Medical Care Visits Among Children with Conditions, by CAM use 2007 NHIS

0%

5%

10%

15%

20%

25%

30%

35%

40%

17.6%

36.5%

18.7%21.2%

35.3%

30.6%

7.4%

25.1%

9.5%11.8%

16.0% 16.2%

Among CAM users Among non-CAM users

AO

R:

1.90

*

Ref

.

AO

R:

2.44

*

AO

R:

2.19

*

Ref

.

Ref

.

Ref

.

Ref

.

Ref

.

AO

R:

3.27

*

AO

R:

2.75

*

2007 NHIS

AOR: adjusted by age, sex, race/ethnicity, income and CSHCN status (for all children ONLY)

AO

R:

2.07

*

For pop up only

All children (n=2,411)

Among CSHCN in

MEPS (n=414)

0%

5%

10%

15%

20%

25%

30%

35%

40%

17.2%

38.4%

6.5%

19.1%

Re

f.AO

R

2.69

*

Ref

.AO

R:

2.31

*

2008 MEPS

Getting Needed Specialist Care for CSHCN, By CAM Use (NS-CSHCN)

CAM use status

NS-CSHCN received all needed SC (among who

needed care)

Access

CSHCN90.8%

(n=18026)

Among CAM users86.5%

AOR: 0.48 (0.37-0.63)

Among non-CAM users91.5%

Ref: 1.00

Specialist Care, by CAM Use and CSHCN Status, NHIS

2007 NHIS

Survey Item CAU.240_00.000: DURING THE PAST 12 MONTHS, have you seen or talked to the following about [S.C. name]'s health?

Inclusion/ exclusion of specialty

A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/ gynecologist, psychiatrist or ophthalmologist?- asked separately)

All children 13.2% (n=1183

Among CSHCN 30.6% (n=604)

Among CAM users

23.3%AOR: 1.58 (1.25-1.98)

39.3%AOR: 1.50 (1.08-2.08)

Among non-CAM users

11.4%Ref: 1.00

28.3%Ref: 1.00

*CAHPS section of MEPSNOTE: AOR: after adjusting age, sex, race/ethnicity, income, CSHCN status (for all children ONLY) and adult CAM use

Results: CAM use and Health Care Access Problems: Delay Getting Care

All ch

ildre

n

Amon

g CSHCN

Amon

g non

-C...

0%

5%

10%

15%

20%

25%

30%

11.9%

21.2%

9.5%

22.1%

28.6%

17.7%

No delayd care reportedYes, delayd care was reported

AO

R:

2.02

*

AO

R:

1.75

*

Ref

Ref

2007 NHIS

0%

3%

6%

9%

12%

15%

18%

8.3%

15.4%

Series 1

CSHCN

Ref

AO

R:

2.26

*

2009/10 NS_CSHCN

CAM Use and Quality of Care: Never/Sometimes Doctors Communicate Well, by Condition Status

and Type, NHIS/MEPS

AOR are adjusted by age, sex, race/ethnicity, income and region (CSHCN status for all children)*RSE>30

Condition types Among CAM users

Among non-CAM users

All children (n=2411)

(controlling CSHCN in MEPS)

13.8%AOR: 1.71 (1.01-2.88)

9.9% Ref: 1.00

(controlling CSHCN in NHIS)

AOR: 1.71 (1.00-2.94) Ref: 1.00

Among children with at least 1 chronic condition (n=1279)

14.8% AOR: 2.20 (1.23-3.95)

9.7%Ref: 1.00

Among, children with emotional, behavioral or mental conditions (n=351) 14.9%*

AOR: 3.34 (1.02-10.90)7.5%

Ref: 1.00

Among children with pain-related condition (n=298)

9.1%*AOR: 1.64 (0.52-5.18)

10.1%*Ref: 1.00

Among children with gastroenterology problem (n=633)

19.2%AOR: 3.36 (1.41-8.01)

9.1% Ref: 1.00

All children Among CSHCN (MEPS) Among children with EMB condition

0%

5%

10%

15%

20%

25%

9.3% 9.0%7.5%

18.7%

22.7%

14.9%

Non-CAM users CAM users

n=34 n=31 n=12 n=82 n=28

AC27: Thinking about the types of medical, traditional and alternative treatments that (READ NAME(S) BELOW) are happy with, how often does {a medical person at} (PROVIDER) show respect for these treatments?

Never/sometimes show respect

Quality of Conventional Care and CAM use Status, by Condition Type Child Experiences

n=152

All children Among CSHCN (MEPS) Among children with EMB condition

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

27.2%

16.1% 15.1%15.2%

26.8%

38.6%

Non-CAM users CAM users

n=51 n=47 n=17 n=34 n=21

AC28: If there were a choice between treatments, how often would {a medical person at} (PROVIDER) ask (READ NAME(S) BELOW) to help make the decision?

Never/sometimes ask to help make the decision

Quality of Conventional Care and CAM use Status, by Condition Type Child Experiences

n=265

CAM use and Total and Out-Of-Pocket Health Care Expenditures (Adjusted),

NHIS/MEPSTotal health care expenditures

CAM use statusChildren with

expense Mean after adjusting covariatesMedian after

adjusting covariates

n % Mean CI p Mean CI p

All children (n=2411) 2014 84.5% $1,462 (1,401-1,522) NA $999

CAM users (n=294) 263 91.0% $2,281 (2,079-2,483)<.0001

Non-CAM users (n=2094) 1734 83.6% $1,319 (1,265-1,374)

Note: Expenditures were estimated by 2-part model adjusting age, sex, race/ethnicity, income, region and CSHCN status (NHIS)

Out-of-pocked health care expenditures

CAM use statusChildren with

expenseMean after adjusting

covariatesMedian after

adjusting covariates

n % Mean CI p Mean CI p

All children (n=2411) 1411 64.8% $305 (284-326) $152

CAM users (n=294) 204 75.4% $426 (367-486) <.0001

Non-CAM users (n=2094) 1194 63.1% $285 (264-306)

CSHCN in NHIS - Algorithm (NHIS) n=440

CSHCN in MEPS - Screener (NHIS/MEPS) n=76

0%

20%

40%

60%

80%

100%

55.6%64.1%

22.3%23.1%

22.1% 12.8%

1 type of CAM 2 types of CAM 3 or more types of CAM

Number of CAM Modalities Used Among CSHCN CAM Users, 2007 NHIS and NHIS/MEPS

Table x

RSE>30

Prevalence of CAM Use By Unmet Needs for Conventional Medical Care

All children Among CSHCN Among non-CSHCN0%

5%

10%

15%

20%

25%

30%

12.3%

21.8%

9.9%

16.3%

22.9%

11.9%

24.5%

29.1%

17.1%

No unmet need 1 unmet need 2 or more unmet needs

2007 NHIS

Ref

AO

R:

1.23

AO

R:

1.71

*

AO

R:

1.24

*

AO

R:

1.71

*

Ref

CSHCN0%

3%

6%

9%

12%

15%

18%

10.3%

12.5%

16.6%

Unmet need for 14 services for any reason

2009/10 NS-CSHCN

AO

R:

1.63

*

AO

R:

2.38

*

Unmet needs for 5 services due to cost

Ref

*statistically significant