the cshcn screener key findings, methods issues, and its relationship with well-being
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Centers for Disease Control and Prevention National Center for Health Statistics. The CSHCN Screener Key Findings, Methods Issues, and its Relationship with Well-Being. Stephen J. Blumberg, PhD Christina D. Bethell, PhD, MBA Paul W. Newacheck, DrPH. 27 July 2011 - PowerPoint PPT PresentationTRANSCRIPT
Stephen J. Blumberg, PhDChristina D. Bethell, PhD, MBA
Paul W. Newacheck, DrPH
The CSHCN ScreenerKey Findings, Methods Issues, and its
Relationship with Well-Being
Centers for Disease Control and PreventionNational Center for Health Statistics
27 July 20113rd Conference of the International
Society for Child Indicators University of York
Children with Special Health Care Needs
The CSHCN ScreenerKey Findings, Methods Issues, and its
Relationship with Well-Being
Centers for Disease Control and PreventionNational Center for Health Statistics
27 July 20113rd Conference of the International
Society for Child Indicators University of York
U.S. National Survey ofChildren’s Health (NSCH)
Dates: 2003, 2007, 2011 Conducted by: National Center for Health Statistics Purpose: Produce estimates on the health and well-
being of children, families, & their communities Sample: Independent random-digit-dial (RDD) samples
for all 50 states & the District of Columbia (DC) Random selection: One child 0 – 17 years of age
selected from each household with children to be the subject of the interview
Goal: Complete interviews for over 91,000 children nationally (goal: 1,700 completed per state & DC)
Respondent: Parent or guardian
NSCH Sponsor
Has primary responsibility for promoting and improving the health of U.S. women, children and families.
Provides leadership to improve the physical and mental health, safety and well-being of the MCH population
Administers block grants to state MCH agencies
Title V MCH Block Grants
The US federal government budgets more than $1 billion annually for MCH services
In order to be entitled to payments, states must use at least 30 percent of such payment amounts for services for children with special health care needs (CSHCN)
Why CSHCN?– CSHCN account for 42% of total medical care costs
(excluding dental costs)
Definition of“Children with Special Health Care Needs”
“Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” (McPherson, Arango, Fox, et al., 1998)
Home Environment Indicators
CSHCN Non-CSHCN4+ family meals together per week 76.0% 77.1%
No tobacco smoke in home 89.9% 93.0%
Watch less than 2 hours of TV per day 45.7% 49.4%
No television in bedroom (age 6-17) 45.6% 51.1%
Parent met all/most friends (6-17) 79.7% 80.9%
Usually/always does all homework (6-17) 77.4% 88.9%
Ever breastfed (age 0-5) 68.3% 76.5%
Told stories or sung to every day (0-5) 65.4% 58.2%
All of the above 22.7% 30.1%
Data Source: NSCH, 2007
Neighborhood and School Indicators
CSHCN Non-CSHCNUsually/always engaged in school 69.5% 83.7%
Never repeated a grade 81.5% 91.8%
Participate in after school activities 77.2% 81.7%
Usually/always safe at school 88.8% 89.8%
Usually/always safe in community 84.4% 86.4%
Live in supportive neighborhood 80.4% 83.9%
Safe and supportive 48.6% 51.8%
Data Source: NSCH, 2007
Indicators Related to Social Behaviors, Activities, and Family
CSHCN Non-CSHCNAge 6-17:
Has problematic social behaviors 17.9% 6.2%
Lacks consistent positive social skills 12.3% 4.6%
No vigorous physical activity 13.2% 9.5%
Does not get adequate sleep daily 41.1% 34.1%
All ages:Mother’s health less than very good 52.2% 41.0%
Father’s health less than very good 41.8% 36.3%
Does not share ideas or talk to parents about things that matter
37.4% 28.1%
Parents usually/always stressed 20.0% 7.9%
Data Source: NSCH, 2007
Definition of“Children with Special Health Care Needs”
“Children with special health care needs are those who have ... a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” (McPherson, Arango, Fox, et al., 1998)
Special Health Needs Continuum
No special healthcare needs
At risk for developing a special health care need
On going health conditions;above average service use needs;few to moderate functionallimitations
On going healthconditions; high or complexservice use needs; moderateto severe functional limitations
GROUP BGROUP A GROUP C(A + B + C)
MOST INCLUSIVE DEFINITIONSinclude “at risk” groups
BROADER DEFINITIONSinclude those with wider array of
conditions, levels of severityand service use needs
(B + C)
NARROWER DEFINITIONSinclude only those with
very severe conditions or highlycomplex needs
(C only)
Defining Special Health Care Needs
What is the CSHCN Screener? A non-condition-specific, consequences-based method for
identifying CSHCN, targeting Categories B and C Designed in 1998-2000 by the Child and Adolescent
Health Measurement Initiative (now at OHSU) Developed through a national process involving
physicians, state leaders, families, methods experts, and policymakers
Tested with parents of 36,000+ children during development phase
Several versions tested, leading to final version, which takes 1 minute for parents to complete
Data for more than 1 million children analyzed since 2000
The CSHCN Screener
Asks about five “common” consequences1. Limitation of activities2. Need for or use of prescription medication3. Need for or use of specialized therapies4. Above routine need or use of medical, mental
health, or education services5. Need for or receipt of treatment or counseling
for an emotional, behavioral, or developmental problem
(Bethell, Read, Stein, Blumberg, Wells, & Newacheck, 2002)
The CSHCN Screener
Two follow-up questions1. Is this due to a medical, behavioral, or other
health condition?2. Is this a condition that has lasted or is expected
to last 12 months or longer?
(Bethell, Read, Stein, Blumberg, Wells, & Newacheck, 2002)
Key Features of CSHCN Screener
Based on parent report– Most amenable to uniform data collection
Short (1 minute to complete)– Costs per item are usually high in government surveys– Longer surveys threaten participation rates
Based on consequences rather than conditions– Condition checklists tend to be very long– Condition checklists are hard to analyze and interpret– Focus on consequences helps capture children with
conditions not yet diagnosed or poorly recalled
Group id’d byCSHCN Screener
SURVEY PARENTS- Ask about specific health services children need or use- Ask about child health status & impact of any health problems
SURVEY PARENTS- Ask to name any specific diagnoses or health conditions children have
CLINICAL EVALUATION- Review of children’s medical charts by pediatric clinicians
MEDICAL RECORDS- Examine encounter & claims data for diagnoses listed in children’s records
COMPARE to:- CYSHCN identified by other methods or definitions such as program eligibility- Children not identified
“Triangulate” to Validate
Cross-Method Comparisons
Over 93% of identified CSHCN had at least one specific chronic health condition or problem, and most had two or more
Over 98% of identified CSHCN had some type of functional difficulty, as defined by the International Classification of Functioning (ICF)
Who is Identified by the Screener?
All or nearly all children with complex health conditions such as:– Cerebral palsy; cystic fibrosis; muscular dystrophy– Rare metabolic or genetic disorders– Mental retardation; developmental delay; autism– Sickle cell anemia; Down Syndrome; diabetes
Only those children whose asthma, ADHD, allergies, or other conditions result in:– Elevated service use,– Long-term use of prescription medicine, or– Limitations in functioning
Who is Missed by the Screener?
The CSHCN Screener is likely to miss children who have only:– Food or environmental allergies– Special diet (e.g., lactose intolerance)– Vision problems (e.g., amblyopia, colorblindness)– Developmental delays early in life
Some parents of children with speech problems, learning disabilities, developmental delay, and conduct problems report consequences but then say they are not due to “health conditions”
Over-Identification?
Should ongoing need for only prescription medication be considered a special need?
Should children with only asthma or allergies be considered CSHCN?
CSHCN with only Rx needs
CSHCN with only asthma or
allergies
Non-CSHCN
Mean # of doctor visits in past year
4.1 4.5 2.3
% with 2+ hospital emergency visits
13.9 16.2 4.8
Data Source: NS-CSHCN, 2005-2006
Survey-Based Uses of the CSHCN Screener in the U.S.
National Survey of CSHCN (NS-CSHCN) National Survey of Children’s Health (NSCH) Medical Expenditure Panel Survey (MEPS) Consumer Assessment of Health Plans Survey
(CAHPS)
Prevalence Differences by Survey
12.8%13.9%
17.6%19.2% 19.3% 18.8%
0%
5%
10%
15%
20%
Prevalence of CSHCN in United States
Data Sources: see legend
NS
-CS
HC
N 2
001
NS
-CS
HC
N 2
005-
06
NS
CH
200
3
NS
CH
200
7
ME
PS
200
1
ME
PS
200
4
Why Might Prevalence Rates Differ Across Surveys?
Dates of data collection
Method of data collection and estimation– Mode– Sampling frame– Interviewers– Weighting methods
Sample size and sampling error
Method of identification– Respondent– Recall period– Question wording– Question ordering– Question context
and introduction
Percent of CSHCN with Each Consequence Type, by Survey
0%
20%
40%
60%
80%
100%
PrescriptionMedications
Service Use /Need
FunctionalLimitations
SpecialTherapies
Mental Health
NS-CSHCN 2001 NS-CSHCN 2005-2006NSCH 2003 NSCH 2007MEPS 2001 MEPS 2004
Data Sources: see legend
Demographic DifferencesPrevalence by Age
8.8%
16.0% 16.8%
0%2%4%6%8%
10%12%14%16%18%
0-5 Years 6-11 Years 12-17 Years
Prevalence by Sex
16.1%
11.6%
0%2%4%6%8%
10%12%14%16%18%
Male Female
Prevalence by Income
14.0% 14.0% 13.5% 14.0%
0%2%4%6%8%
10%12%14%16%18%
0-99% FPL 100-199%FPL
200-399%FPL
400% + FPL
Prevalence by Race/ Ethnicity
15.5% 15.0%
8.3%
0%2%4%6%8%
10%12%14%16%18%
Non-HispanicWhite
Non-HispanicBlack
Hispanic
Data Source: NS-CSHCN, 2005-2006
Prevalence by Race/Ethnicity and Primary Language at Home
4.6%
13.1%15.6%
0%
5%
10%
15%
20%
Hispanic / Spanish Hispanic / English NH White / English
Data Source: NS-CSHCN, 2005-2006
Prevalence by Race/Ethnicity and Primary Language at Home
0%
3%
6%
9%
12%
15%
PrescriptionMedications
Service Use /Need
FunctionalLimitations
SpecialTherapies
Mental Health
Hispanic / Spanish Hispanic / English NH White / English
Data Source: NS-CSHCN, 2005-2006
Prescription Medication Orders Filled, by Ethnicity and Language of Interview
36.8%
0.8%
45.8%
5.4%
54.5%
6.2%
0%
10%
20%
30%
40%
50%
60%
Hispanic / Spanish Hispanic / English NH White / English
Data Source: MEPS, 2004
Percent of Children with Any Prescription
Medication Orders
Percent of Children with Any Psychiatric Medication Orders
Thanks to Byron A. Foster, Oregon Health and Science University.
The CSHCN Screener
Reliably identifies children requiring on-going medical and other health-related services
Can be used to stratify children into meaningful subgroups related to condition complexity
Is sensitive to health care practice patterns (such as those related to cultural differences)
Yields results that can be influenced by differences in survey administration
Provides a key health indicator that is related to the home environment and the well-being of children and their families