Using The National Health Interview Survey and

USINGTHENATIONALHEALTHINTERVIEWSURVEYAND
MEDICALEXPENDITUREPANELSURVEYTOASSESSTHEUSE
ANDIMPACTOFCOMPLEMENTARYANDALTERNATIVE
MEDICINEAMONGCHILDRENINTHEUNITEDSTATES:
AMETADATAMETHODSKEYISSUESREPORT
ChristinaBethell,PhD,MBA,MPH1,NarangerelGombojav,PhD1,ScottStumbo,MA1,CambriaBrown,
MPH1,StephenBlumberg,PhD2,AdamCarle,PhD3,PaulWNewacheck,DrPH4
1
ChildandAdolescentHealthMeasurementInitiative,OregonHealthandScienceUniversity,Portland,OR;2DivisionofHealth
3
InterviewStatistics,NationalCenterforHealthStatistics,Hyattsville,MD; CinncinatiChildrensHospitalMedicalCenter,James
4
M.AndersonCenterforHealthSystemsExcellence,Cincinnati,OH; InstituteforHealthPolicyStudies,UniversityofCalifornia,
SanFrancisco,CA
ThereportwassupportedbyagrantfromtheNationalCenterforComplementaryandAlternativeMedicine(#1R21AT00496001A2).
SuggestedCitation:Bethell,C,Gombojav,N,Stumbo,S,Brown,C,Blumberg,S,Carle,A,Newacheck,PW.UsingtheNational
HealthInterviewSurveyandMedicalExpendituresPanelSurveytoAssesstheUseandimpactofComplementaryand
AlternativeMedicineforChildrenintheUS:AMetaDataMethodsKeyIssuesReport.2013.TheChildandAdolescentHealth
MeasurementInitiative.Availableat:http://childhealthdata.org/docs/drc/cammetadatareport.pdf.
TableofContents
Introduction..................................................................................................................................................3
DataSourcesandDataFileLinkage..............................................................................................................4
VarianceEstimationintheNHIS/MEPSLinkedFile......................................................................................6
SampleSizeSufficiency.................................................................................................................................7
CAMUseDefinitions...................................................................................................................................10
ConditionsAskedAboutintheSampleChildCoreversusConditionsParentsNamedAsReasonforCAM
UseintheChildCAMSupplement..............................................................................................................16
CapacitytoReadilyIdentifyChildrenwithSpecialHealthCareNeeds(CSHCN)........................................18
CapacitytoCompareHealthStatus,HealthOutcomesandConventionalMedicalCareUtilizationacross
TimeforMatchedChildrenWhoUseorDoNotUseCAM.........................................................................25
Tables
Table1.CAMUseEstimatesinNHIS/MEPSLinkedFile................................................................................6
Table2A.IncomeEstimatesinNHISandNHIS/MEPSFiles(VariableSource:2007NHIS)...........................7
Table2B.IncomeEstimatesinNHISandNHIS/MEPSFiles(VariableSource:2008MEPS)..........................7
Table2C.TheEstimatedDistributionWhenWeightsAreNotAdjustedintheNHIS/MEPSLinkedFile.
(VariableSource:2007NHISmatchedyearofCAMuseforchildren).......................................................7
Table3.UseofSpecificCAMModalities,DataSource:2007NHIS..............................................................8
Table4.AccesstoandQualityofHealthCareamongAllChildren,CAMUsersandNonCAMUsers,Data
Sources:2008MEPSandNHIS/MEPSLinkedDataFiles...............................................................................9
Table5.DemographicCharacteristicsofChildren,byCAMUseDefinitions,DataSource:2007NHIS.....12
Table6.ChildrensHealthStatus,InsuranceTypeandHealthCareUtilizationandAccess:byCAMUse
Definitions,Datasource:2007NHIS...........................................................................................................13
Table7.PrevalenceofCAMUse,byChildrensHealthStatus,InsuranceType,HealthCareUtilizationand
Access,DataSource:2007NHIS.................................................................................................................14
Table8.DemographicCharacteristics,HealthStatusandMedicalCareUtilizationofChildren,byStatus
ofVitamins/MineralsUse...........................................................................................................................15
Table9.ChildrenUsedCAMWhoseParentsNamedtheSameConditionintheSampleChildCoreand
theChildCAMSupplement(SelectedConditions).....................................................................................17
Table10.RelationshipBetweenConditions/ProblemsReportedinSampleChildandChildCAMFiles,by
SelectedCAMModalities............................................................................................................................17
Table11.Demographic,Health,HealthCareRelatedCharacteristicsofChildrenWhoMetBoththe
CCCESUNAlgorithm(NHIS)andtheCSHCNScreenerCriteria(MEPS)andPositivelyIdentifiedbyEither
CCSESUNAlgorithmOnlyorCSHCNScreenerinMEPS,Datasources:......................................................20
Table12.CCCESUNIdentifiedbytheCCCESUNAlgorithminNHISandCSHCNIdentifiedbytheCSHCN
ScreenerinMEPSMettheQualifyingCriteria............................................................................................21
Table13.ChildrenWhoMetQualifyingCriteria,SurveyComparison........................................................21
Table14.ChildrenWhoMetBoththeNHISAlgorithmandtheCSHCNScreenerCriteria(MEPS)and
PositivelyIdentifiedbyEithertheCCCESUNAlgorithmOnlyortheCSHCNScreenerinMEPSMet
QualifyingCriteria,DataSources:2007NHIS,2008MEPSandNHIS/MEPSLinkedFile.............................22
Table15.ConsequencesQualifyingCriteriaSurveyItems.........................................................................23
Table16.PrevalenceofChronicConditionsamongCCCESUNandCSHCN................................................24
Table17A.SpecialistCare,byCAMUseandCSHCNStatus,DataSources:NHISandNHIS/MEPSLinked
File...............................................................................................................................................................26
Table17B.Hospitalization,byCAMUseandCSHCNStatus,DataSources:NHISandNHIS/MEPSLinked
File.............................................................................................................................................................266
Table17C.HealthOutcome:Missed11orMoreSchoolDays,byCAMuseandCSHCNstatus,Data
Sources:2007NHISandNHIS/MEPSLinkedFile......................................................................................267
Figures
Figure1.Mergingthe2007NHISandthe2008MEPSDataFiles.................................................................5
Figure2.PrevalenceofCAMUseinDifferentDataSets,byCCCESUNandCSHCNStatus........................19
Figure3.UtilizationofEmergencyRoominTime1andFutureYearofCAMUse(Time2),.................25
CommonlyUsedAbbreviations
CAM
ComplementaryandAlternativeMedicine
CAHMI
ChildandAdolescentHealthMeasurementInitiative
CCCESUN
Childrenwithchronicconditionsandelevatedserviceuseorneed
CSHCN
ChildrenwithSpecialHealthCareNeeds
EMB
Emotional,mentalorbehavioral
MEPS
MedicalExpenditurePanelSurvey
NCCAM
NationalCenterforComplementaryandAlternativeMedicine
NCHS
NationalCenterforHealthStatistics
NHIS
NationalHealthInterviewSurvey
NSCH
NationalSurveyofChildrensHealth
NSCSHCN
NationalSurveyofChildrenwithSpecialHealthCareNeeds
UsingtheNationalHealthInterviewSurveyandMedicalExpendituresPanelSurveytoAssesstheUseandimpactof
ComplementaryandAlternativeMedicineforChildrenintheUS:AMetaDataMethodsKeyIssuesReport.2013.

Introduction
Thisreportdescribeskeymethodologicalaspectsandissuestoconsiderwhenusingthe2007National
HealthInterviewSurveydatafiles(NHIS)andthelinkedfile of the2007NHISandthe2008Medical
Expenditure Panel Survey (MEPS) to evaluate use and impact of complementary and alternative
medicine(CAM)amongUSchildren.
Complementaryandalternativemedicine(CAM)useamongchildrenandadolescentshasbecomeas
prevalentastheuseofmanytypesofconventionalmedicalcareservices.1Consequently,CAMoriented
researchcontinuestoexpand.2ThoughintegratingCAMwithconventionalmedicalcareisessential3to
providingcomprehensivehealthcarewithinamedicalhome,CAMremainssegmentedfrom
conventionalpediatricmedicalcare.Thismayinpartbeduetogapsinpopulationbasedevidenceof
factorscontributingtovariationsinCAMuseamongchildren,suchasachildshealthstatus,health
condition(s)andhealthinsurance,aswellasassociationsbetweenCAMuseandconventionalmedical
careuseaccordingtoqualityandexpenditures.Therefore,furtherevidenceisneededtoinformand
prioritizefutureclinicalinvestigationsinadditiontoadvancingeffectivecaredeliveryandfinancing
modelsintegratingCAMwithconventionalpediatricmedicalcareasappropriate.
DataonCAMutilizationamongadultswerecollectedinthe1999,2002and2007NationalHealth
InterviewSurvey(NHIS).Nationallyrepresentative,populationbaseddataonCAMuseamongchildren
age017yearsbecameavailablewhentheChildCAMSupplementwasaddedtothe2007NHIS.Hence
forth,theChildandAdolescentHealthMeasurementInitiative(CAHMI)soughttocontributetothe
nascentfoundationofhealthservicesknowledgeregardingtheuseandimpactofCAMamongchildren
by:(1)adaptingexistingCAMhealthservicesresearchmodelsandmeasurementmethodstoreflectthe
uniquecharacteristicsofchildrenandchildrenshealthcare;and(2)placingtheuseofCAMamong
childrenwithinthecontextoftheirhealthstatus,demographics,socialandparentalcharacteristicsand
theirinteractionsandexpendituresforconventionalmedicalcare.Thestudywassupportedbya
NationalCenterforComplementaryandAlternativeMedicine(NCCAM)sponsoredgrant.Thestudy
usedpubliclyavailable2007NHISdatafilesandthelinkedfileofthe2007NHISandthe2008MEPS.
ThelinkageofNHISandMEPSdataallowsevaluatingassociationsbetweenCAMuseandconventional
medicalcareexpenditures,accessandqualityamongchildren.Moreover,itispossibletoexaminethe
impactofCAMuseonchildhealthoutcomeandhealthservicesutilizationusingthelinkedNHISand
MEPSdatasets.Thebroadarrayofdatapointsavailableforeachchildhavethepotentialtoprovidea
richassessmentofachildshealth,sociodemographiccharacteristics,healthservicesutilizationand
outcomes.Still,itisimportanttoconsidertheuniqueaspectsofusingthesedatasetstogetherandthe
possiblelimitations.
The report provides information on weighting, sample size and limits of the linked data sets, validity
evaluationandvariableconstructionusingcurrentlyavailablepopulationbaseddatafiles.Weproposed
tomaximizetheuseofavailabledataintheprocessofidentifyinglimitations.
DataSourcesandDataFileLinkage
Two national survey data files were used: the 2007 National Health Interview Survey (NHIS)4 and the
2008MedicalExpenditurePanelSurvey(MEPS).5
TheNationalHealthInterviewSurvey
TheNHISisanongoing,nationallyrepresentativehealthsurveyoftheUScivilian,noninstitutionalized
populationconductedbytheNationalCenterforHealthStatistics(NCHS).NHISusescomputerassisted
personal interviewing for its data collection. The 2007 NHIS consists of Basic Core and Supplemental
Questionnaires. The Basic Core includes three components: the Family Core (Householdlevel file,
Familylevelfile,Personlevelfile,Datafilesoninjuriesandpoisoning),theSampleChildCoreaandthe
Sample Adult Core. The Family Core component collects data on everyone in the family, whereas
informationononerandomlyselectedadultorchildfromeachfamilycollectedintheSampleAdultor
Sample Child Cores. The two additional supplements in 2007 are the Adult Complementary and
Alternative Medicine (CAM)andtheChildCAMa SupplementsthatcollectinformationaboutCAMuse
fromsampleadultsorsamplechildren.
For the 2007 NHIS, 75 764 individuals, including 20 719 children age 017 years from 29 915 families,
were interviewed. There were 9 417 sample children 017 years of age randomly selected from each
family, representative of 73.7 million US children, for whom: (1) sociodemographic characteristics,
healthconditionsorproblemsexperiencedeverorinthepast12monthsandconventionalhealthcare
experienceandutilizationinformationwasavailableintheSampleChildFile,and(2)informationon39
typesofspecificCAMmodalityusewasavailableintheChildCAMFile.
TheMedicalExpenditurePanelSurvey
TheMEPSisanongoingsurveydesignedtoprovidenationallyrepresentativeestimatesofmedicalcare
use and expenditures among the US civilian, noninstitutionalized population. An overlapping, panel
design with five rounds of computerassisted personal interviews spanning two full calendar years is
used for MEPS. Households are selected from the households that participated in the previous years
NHIS.ThehouseholdsselectedfortheMEPSPanel12wereasubsampleofthe2006NHIS,andMEPS
Panel13sampleswereselectedfromthe2007NHISrespondinghouseholds.SomeNHISnonresponding
householdsparticipateinMEPS.The2008MEPSsampled33066individualstotal,including13095for
Panel12and19971forPanel13.Ofthosesampled,9538childrenage017years(3654forPanel12
and5884forPanel13)wereeligiblefortheChildHealthandPreventiveCaresection(Rounds2and4).
LinkageoftheNHISandMEPSDataSets
The 2008 MEPS Full Year Consolidated Household File was linked to the NHIS data files to obtain
utilization, quality of conventional medical care and expenditure data (Figure 1). Since CAM
supplementaldatawerecollectedinthe2007NHIS,onlyMEPSPanel13datawerelinkedtothe2007
NHIS. Of the 19 971 adults and children included in the MEPS Panel 13 overall samples, 17 764 were
linked totheNHISfiles.Fromalladultandchildsampleslinked tothe NHIS, 2 411were NHISsample
children.bTheappropriateMEPSeventfiles,suchasMedicalConditions,OfficebasedMedicalProvider
VisitsandPrescribedMedicinesfiles,werealsolinked.
Technicalnote:NCHSprovidedtwosupplementalfileswithtwodummyrecordstofillinthemissingsampledesigninformationfor
SampleChildandChildCAMFiles.Thesesupplementalfilesweremergedtotheappropriatefilesbeforelinkingtootherdatasetsand
theywereexcludedfromtheseanalysesbyusingtheSubpopulationcommandinSPSSsComplexSamplesprogram.4
b
Technicalnote:Eachyear'sMEPSfileonlycontainsasubsetofpersonsfromthepreviousNHIScorepersonfile.Additionally,manyof
theNHISfiles,particularlythesampleadultfile,willonlymatchtoasubsetoftheMEPSfile,andtheresultingmatchedsamplesizes
maybequitesmall.6
2007NHISDataFiles
Figure1.Mergingthe2007NHISandthe2008MEPSDataFiles
2008MEPSDataFiles
OverallsamplesintheNHIS/MEPSlinkedfile=
75,764NHIStotalsample+33,066MEPStotalsample(Panels12and13) 17,764 (TheMEPSPanel13sampleslinkedtotheNHIS)=91,066
PersonFile
(n=75764)
ChildCAM
File*
(n=9417)
SampleChild
File*
(n=9417)
FamilyFile
(n=29915)
2007NHIS
LinkedDataFile*
(n=75764individuals,
9417children)
AdultCAM
File
(n=23393)
Imputed
IncomeFile
#1(single
imputation)7
Medical
Conditions
File
(n=102169)
17,764**
MEPSPanel
13samples
linkedtoNHIS
NHIS/MEPSLinkedFile*
(n=91066allindividuals)
2411childrenhavedata
frombothsurveys
Sample
AdultFile
(n=23393)
2008MEPS
FullYear
Consolidated
DataFile
(n=33066)
OfficeBased
Medical
ProviderVisits
(n=136460)
Prescribed
Medicines
File
(n=293379)
*DatasetsIncludetwoadditionaldummyrecordstofillinmissingsampledesigninformation.Thesubpopulationsubcommandwasusedforanalysestoexcludethesedummycases.
**TheOverallMEPSPanel13samples=19,971;ofthose2,207cannotbe linkedtotheNHIS:19,9712,207=17,764
VarianceEstimationintheNHIS/MEPSLinkedFile
EstimatesintheNHIS/MEPSlinkedfilevarydependingontheweightsusedfordataanalysis.The
NationalCenterforHealthStatistics(NCHS)recommendsusingtheMEPSsampledesignvariablesand
weightsforanyanalysisusingalinkedNHIS/MEPSfile.Inaddition,theweightsprovidedintheMEPS
fileswouldhavetobeadjustedtoaccountforthosepersonswhoareintheMEPSfiles,butarenotin
theNHISfiles.6
The adjusted weights for the 2007 NHIS and 2008 MEPS linked file were constructed through the
followingsteps:
(a) TheMEPSPanel13weightswerecalculatedmultiplyingthe2008compositepersonweightsby
factor1.64.
WTPNL13C=MEPSPersonweightsx(MEPStotalpop.est./Panel13pop.est.)
TheMEPSPanel13specificweightsarenotavailableonpublicusefiles.ThePanel13Longitudinalfilehaspanel
specific weights, but adjustments were made in the construction of the panel weights to compensate for the
attrition of persons in the panel who participated in the survey for only part of the period were inscope. The
LongitudinaldatafilecontainsfewersamplesthantheFullYearConsolidatedDatafile(n=18287outof19971).
(b) Panel13weightswereadjustedtoreflecttheNHISprobabilitiesofselectionforsubsampling
ofchildren.
NHISMEPSWT=WTPNL13C/(WTFA/WTFA_SC)8
(c) Thelinkedfileadjustedweightswererakedbyage,sex,race/ethnicityandUSregionbyusing
the2007NHISpopulationcontroltotalsasastandard.9
Table 1 displays variation in estimates of CAM use among children according to the different weights
applied.WhenusingthelinkedfileadjustedweightsintheNHIS/MEPSlinkedfile,theestimateofthe
child population that used CAM (N=12 305 184) is not significantly different than the population
estimateofCAMusersweightedbythesamplechildweightsinthe2007NHIS(N=10621653,p=0.17).
The prevalence estimates of CAM users were also not significantly different among all children in the
linkedfilewhentheNHISsampleweightswereusedcomparedtowhenthelinkedfileadjustedweights
were used (14.7 percent vs. 16.9 percent, p=0.10). Among children with special health care needs
(CSHCN)identifiedbytheCSHCNScreener10inMEPS,thepercentestimatesofCAMuseweightedbythe
MEPSpersonweightsversuslinkedfileweightswerenotstatisticallysignificantlydifferent(26.5percent
vs.24.7percent,p=0.67).
Table1.CAMUse*EstimatesinNHISandNHIS/MEPSLinkedFile,byDifferentWeights
Denominator
AmongallNHISsample
children(n=9417)
AmongNHISsample
childrenlinkedtoMEPS
(n=2411)
AmongCSHCN(n=410)
AmongNonCSHCN
(n=1745)
NHISSampleChild
Weights
MEPSPersonWeights
LinkedFileAdjusted
Weights
Pop.est.(SE)
W%(SE)
Pop.est.
W%(SE)
Pop.est.(SE)
W%(SE)
1285
10621653
(429892)
14.6%(0.5)
NA
NA
NA
NA
331
3062901
(282250)
14.7%(1.1)
3580405
(298200)
17.0%(1.2)
12305184
(1134245)
16.9%(1.3)
86
832433
26.5%(2.9)
3238802
24.7%(2.9)
197
1787194
13.7%(1.3)
7563878
14.3%(1.5)
CSHCNstatusinMEPS
21.6%(2.7) 1057061
11.9%(1.1)
2010450
*Consistsof39typesofspecificCAMmodalitiesincludingspecificvitamins/mineralsusedinpast30days(Table3).
Howwouldtheestimateschangeiftheweightadjustmentswerenotapplied?
Comparingtheestimatedfamilyincomedistributionusingdifferentweightsinthedatasetsillustrates
the implications of weight adjustment (i.e. adjustment to account for those persons who are in the
MEPSfilesbutarenotintheNHISfiles).ThedistributionoffamilyincomeintheNHIS/MEPSlinkedfile
weightedbythelinkedfileadjustedweightsisidenticaltodistributionsinthe2007NHISweightedby
theNHISsamplechildweightsandinthe2008MEPSweightedbytheMEPSpersonweights(Tables2A&
2B). However, the population and percent estimates of income in the NHIS/MEPS linked file are
substantiallydifferentiftheunadjustedweightsineitherdatafileareused:NHISsamplechildandMEPS
personweights(Table2C).Forexample,percentestimateofchildsfamilywholivebelowpovertylevel
ishigheriftheNHISsamplechildweightswereusedandloweriftheMEPSpersonweightswereusedin
theNHIS/MEPSlinkedfile.
Table2A.IncomeEstimatesintheNHISandNHIS/MEPSFiles(VariableSource:2007NHIS)
2007NHIS:SampleChildWeights NHIS/MEPS:LinkedFileAdjustedWeights
Income(NHIS)
n=9417;Pop:73727832
n=2411;Pop:73727832
Pop.Estimate
Weighted%(SE)
Pop.Estimate
Weighted%(SE)
099%FPL
13512503
18.3%(0.6)
12833079
17.4%(1.1)
100199%FPL
17922178
24.3%(0.7)
17512971
23.8%(1.1)
200399%FPL
22852213
31.0%(0.7)
22904549
31.1%(1.5)
400%FPLorabove
19440938
26.4%(0.7)
20477232
27.8%(1.5)
Table2B.IncomeEstimatesintheMEPSandNHIS/MEPSFiles(VariableSource:2008MEPS)
2008MEPS:MEPSPersonWeights NHIS/MEPS:LinkedFileAdjustedWeights
(n=9138;Pop:74314212)
(n=2411;Pop:73727832)
Income(MEPS)
Pop.Estimate
Weighted%(SE)
Pop.Estimate
Weighted%(SE)
099%FPL
14,072,660
18.9%(0.9)
14,458,187
19.6%(1.1)
100199%FPL
15,738,688
21.2%(0.8)
15,372,525
20.9%(1.2)
200399%FPL
25,230,784
34.0%(1.1)
25,766,667
34.9%(1.5)
400%FPLorabove
19,272,081
25.9%(1.1)
18,130,454
24.6%(1.3)
Table2C.TheEstimatedDistributionWhenWeightsAreNotAdjustedintheNHIS/MEPSLinkedFile.
(VariableSource:2007NHISmatchedyearofCAMuseforchildren)
NHIS/MEPS:NHISSampleChild
NHIS/MEPS:MEPSPersonWeights
Income(NHIS)
Weights(n=2411;Pop:21083969)
(n=2411;Pop:21201542)
Pop.Estimate
Weighted%(SE)
Pop.Estimate
Weighted%(SE)
099%FPL
5,398,870
25.6%(1.3)
3,059,541
14.4%(1.0)
100199%FPL
5,719,924
27.1%(1.3)
4,583,963
21.6%(0.9)
200399%FPL
5,786,976
27.4%(1.4)
6,461,168
30.5%(1.3)
400%FPLorabove
4,178,199
19.8%(1.1)
7,096,871
33.5%(1.5)
SampleSizeSufficiency
ModalitySpecificDataAnalysis
611years
1217years
Hispanic
White,
NonHispanic
Black,
NonHispanic
Other/MultiNon
Hispanic
Acupuncture
Ayurveda
Biofeedback
Chelation
Chiropractic/osteopathicmanipulation
EnergyHealing
Hypnosis
Massage
Naturopathy
Curandero
Espiritista
Hierbero/Yerbera
Shaman
Botanica
Medicineman
Sobador
Feldenkreis
Alexandertechnique
Pilates
Tragerpsychophysicalintegration
Herbalsupplementspast12m
Vitamins/mineralspast12m
Vitamins/mineralspast30days,of
thosewhousedinpast12months
Homeopathy
Vegetariandiet
Macrobioticdiet
Atkinsdiet
Pritikindiet
Ornishdiet
Zonediet
SouthBeachdiet
Yoga
Taichi
Qigong
Meditation
Guidedimagery
Progressiverelaxation
Deepbreathingexercises
Supportgroupmeetings
Stressmanagementclass
Numberof childrenwhousedtheCAMmodality
AgeGroup
Race/Ethnicity
22
9
16
7
220
21
7
88
25
6
57
7
4
4
12
12
5
8
32
6
320
3713
9
4
5
6
37
7
4
14
10
1
24
1
2
5
5
1
2
3
1
72
1233
2
3
4
1
56
5
2
15
9
3
15
2
2
3
4
1
1
5
91
1314
11
2
7
127
9
1
59
6
2
18
4
2
2
4
3
3
5
24
5
157
1166
5
3
5
2
33
6
3
17
3
5
19
4
2
2
12
2
2
5
2
52
858
12
4
8
4
168
8
4
58
16
1
24
1
2
2
5
24
2
215
2026
2
1
7
2
7
2
11
1
1
1
2
1
20
497
2
2
1
12
5
6
4
3
1
1
1
7
1
1
1
1
33
332
AmongCAM
modalityusers,%
ofchildrenwho
experiencedany
CHORNICOR
NONCHRONIC59
conditionsasked
aboutinSample
ChildFile(n)
84.8%(19)
76.6%(7)
76.6%(13)
74.0%(5)
88.4%(202)
85.6%(18)
72.1%(5)
94.4%(82)
85.5%(21)
86.6%(5)
74.4%(43)
64.4%(4)
91.7%(3)
100%(4)
84.2%(10)
93.9%(11)
40.6%(2)
56.7%(4)
86.5%(27)
63.7%(4)
93.7%(303)
84.8%(3111)
3119
1082
1109
928
690
1737
413
279
84.6%(2606)
59.3%(1843)
96
57
4
9
3
4
4
15
178
15
4
89
29
38
179
59
33
41
17
2
2
1
1
1
1
40
9
5
4
23
1
1
27
19
1
1
1
1
2
4
51
9
1
23
12
11
54
11
6
28
21
1
6
1
2
1
10
87
6
3
57
12
23
102
47
26
15
12
2
3
2
3
2
5
28
1
15
5
8
44
11
5
70
23
1
4
9
117
8
2
55
19
22
103
33
18
2
5
15
1
1
8
2
4
20
9
5
9
17
1
2
1
1
1
18
6
11
3
4
11
6
5
88.3%(90)
82.3%(46)
41.8%(1)
92.3%(7)
57.0%(1)
86.0%(2)
61.8%(2)
94.7%(13)
94.9%(168)
90.3%(12)
100%(4)
95.6%(85)
100%(29)
97.7%(37)
92.7%(171)
100%(59)
97.8%(32)
68.5%(69)
70.3%(39)
41.8%(1)
92.3%(7)
57.0%(1)
86.0%(2)
61.8%(2)
94.7%(13)
71.8%(129)
82.2%(11)
100%(4)
82.6%(74)
89.0%(25)
96.1%(36)
85.6%(156)
94.1%(55)
97.8%(32)
Allchildren
CAMmodalitiesaskedaboutinthe
NHISChildCAMSupplement
(n=9,417)
05Years
The2007NHISChildCAMSupplementaskedabout39specifictypesofCAMmodalitiesusedinthepast
12 months aswellastheuseofherbalsupplementsandvitamin/mineralsinthepast30daysamong
those who used herbal supplement or vitamins/minerals in the past 12 months. However, it is not
possible to use CAM modality specific data analytically because use of specific CAM modalities by
children was so low (Table 3). This suggests that grouping modalities by broader question sets and
reservingmodalityspecificquestionstoamorelimitedsetofitemswouldbebeneficialforsubsequent
dataanalysis.Inaddition,thiswouldservetoshortentheoverallsurvey.
Table3.UseofSpecificCAMModalities,DataSource:2007NHIS
Percentof
childrenusedthe
CAMmodality
whohaveoneor
moreCHRONIC
CONDITIONS(46
conditionsasked
aboutinSample
ChildFile)(n)
68.4%(13)
68.9%(6)
76.6%(13)
74.0%(5)
70.3%(156)
67.0%(15)
72.1%(5)
81.5%(67)
76.9%(19)
75.4%(3)
66.4%(36)
64.4%(4)
91.7%(3)
100%(4)
50.9%(6)
59.2%(8)
40.6%(2)
48.5%(3)
73.2%(24)
63.7%(4)
76.7%(249)
59.5%(2190)
Note:Theshadedcellsdonotmeetstandardsofprecision(relativestandarderrorRSE>30%)
SampleSizeintheNHIS/MEPSLinkedFile
Linkageof theNHISand MEPS datasetsyieldsatotalsample of2,411children. Thisis aninsufficient

samplesizetovalidlyexplorethemanyconditionspecificpatternsandassociationswithconventional
healthcareaccess,qualityandexpendituresthatarecriticaltobetterunderstandingtheneedforand
impact of integrative medicine among children. For example, sample sizes on MEPS items to assess
access and quality of care in the 2008 MEPS Child Preventive Health Supplement Section drops down
nearly fourfold, and the estimated percent of children who used CAM does not meet precision
requirementsforarelativestandarderror(RSE)greaterthan30(Table4).Moreover,thesmallsample
sizerestrictssubpopulationanalysesbasedonspecificconditionsandconditiontypes.
Table4.AccesstoandQualityofHealthCareamongAllChildren,CAMUsersandNonCAMUsers,
DataSources:2008MEPSandNHIS/MEPSLinkedDataFiles
Howwelldoctorscommunicate
Gettingcarequickly
Gettingneededcare
AccesstoandQualityofCare(2008MEPS,
ChildHealthandPreventiveCareSection
Questions)
Receivedneededcare
Howoftenwaseasytogetcare
Never/sometimes
Usually
Always
Neededspecialistcare
Howoftenwaseasytoseeaspecialist
Never/sometimes
Usually
Always
Neededcarerightawaydueto
illness,injuryorcondition
Howoftengetcareassoonasthought
neededrightaway
Never/sometimes
Usually
Always
Neededanyappointmentforhealth
care
Howoftengetanappointmentas
soonasthoughneeded
Never/sometimes
Usually
Always
Healthproviderlistencarefully
Never/sometimes
Usually
Always
Healthcareproviderexplaineasyto
understand
Never/sometimes
Usually
Always
Healthcareprovidershowrespectfor
whatyouhadtosay
Never/sometimes
Usually
Always
MEPSfullsample
n=9138withpositive
weightsoutofeligible
9538children*
UWN
W%*
2973
49.9%
Samplesinthelinked
file(n=2200eligible
fortheCAHPSoutof
2411)**
UWN
W%**
746
49.8%
UsedCAM
(n=289,16.7%**
14.2%***)
DidnotuseCAM
(n=1891,83.3%**
85.8%***)
UWN
129
UWN
606
W%**
48.2%
32
107
466
273
4.2%
16.1%
79.7%
16.1%
158
542
2272
1336
4.2%
16.4%
79.4%
17.0%
46
131
568
345
5.0%
15.8%
79.2%
18.0%
13
22
94
68
W%**
56.0%
8.3%
14.4%
77.3%
27.7%
211
292
802
13.9%
21.6%
64.6%
56
70
206
13.9%
16.4%
69.7%
11
12
42
9.0%
17.7%
73.3%
45
57
161
15.8%
15.9%
68.5%
1806
21.2%
467
22.2%
81
24.4%
383
21.8%
125
246
1434
5.7%
11.7%
82.7%
26
56
385
4.7%
11.0%
84.3%
5
8
68
4.2%
8.2%
87.7%
21
48
314
4.9%
11.8%
83.4%
5543
65.5%
1377
65.7%
207
71.1%
1159
64.7%
398
1063
4067
6.5%
17.4%
76.1%
116
249
1006
7.5%
18.8%
73.7%
20
44
142
7.6%
23.9%
68.5%
95
204
855
7.4%
17.8%
74.7%
302
1244
5118
4.3%
17.2%
78.5%
79
309
1241
4.3%
16.4%
79.2%
22
44
168
5.8%
19.0%
75.2%
56
263
1061
4.0%
15.9%
80.0%
302
1221
5146
3.7%
17.0%
79.3%
87
305
1237
4.5%
16.0%
79.5%
19
42
174
5.1%
13.7%
81.2%
68
258
1053
4.4%
16.5%
79.1%
253
1140
5279
3.8%
15.7%
80.5%
67
272
1290
3.9%
14.6%
81.5%
15
34
162
4.9%
10.3%
84.8%
51
237
1,115
3.8%
15.6%
80.7%
*WeightedbyMEPSPerson**Weightedbythelinkedfileadjustedweightsrakedbyage,sex,raceandregion***WeightedbySamplechildweightsandSUBPOPchildreneligibleforMEPS
CAHPSquestionsinround2Panel13Note:Shadedcellsdonotmeetstandardsofprecision(RSE>30);CAMusedefinitionincludesspecificvitamins/mineralsusedinthepast30days
CAMUseDefinitions
A single accepted definition of CAM does not exist. Consequently, the rates of CAM use vary
substantially across published studies according to the definition of CAM. Many researchers do not
consider vitamins and minerals to be CAM,11,12 possibly due to the perspective that vitamins/minerals
areroutinelyusedforpreventivepurposes.However,accordingtothe2007NHIS,lessthanhalf(43.3
percent)ofchildrenage017yearsusedsometypeofvitamins/mineralsinthepast12months(Table
8).Inaddition,alargeproportion(51.3percent)ofchildrenwithcomplexhealthconditionsorproblems
(childrenwithchronicconditionsandelevatedserviceuseorneedCCCESUN)usedvitamins/mineralsin
thepast12months.Nearlythreequarters(74.6percent)oftheCCCESUNONLYusedvitamins/minerals.
TheNationalCenterforComplementaryandAlternativeMedicine(NCCAM)statesthat,CAMpractices
are often grouped into broad categories, such as natural products, mind and body medicine, and
manipulative and bodybased practices. Natural products include variety of herbal medicines (also
knownasbotanicals),vitamins,minerals,andothernaturalproducts.13
Giventhisdefinition,onemaywonderwhetherornotallvitamins/mineralsareconsideredtobeCAM?
NCCAMclarifiesthate.g.,takingamultivitamintomeetminimumdailynutritionalrequirementsor
taking calcium to promote bone healthare not thought of asCAM.13 The 2007 NHIS data
demonstrate that the estimated prevalence of CAM use among US children varies most notably
accordingtohowtheuseofvitaminsandmineralsisincludedandscored(Table5).Forinstance,the
prevalenceofCAMuseincreasesfourfoldwhenallvitamins/mineralsusedinthepast12monthsare
included compared to when they are excluded from the definition (47.5 percent vs. 12.0 percent,
respectively).
The2007NHISChildCAMSupplementaskedaboutvitamins/mineralsusedinthepast12monthsandin
thepast30days.Thenuseof20specifictypesofvitamins/minerals(includingmultivitaminandvitamin
packets)anduseofvitamins/mineralstotreatspecificconditionsorproblemswereaskedofthosewho
used in the past 30 days. The survey data reveal that among the 43.3 percent of children who used
vitamins/minerals in the past 12 months, the majority of parents reported that they used
vitamins/minerals for their children in the past 30 days (84.6 percent). Among children who used
vitamins/minerals in the past 30 days, 11.8 percent used one of the specific vitamins/minerals, 95.0
percent used multivitamins/mineral combinations or vitamin packets and only 4.2 percent of parents
reportedthatvitamins/mineralswereusedfortheirchildsspecifichealthconditions.
Overall, nine CAM use definitions were developed by the CAHMI to test implications of inclusion and
exclusionofuseofvitamins/minerals.Ofthose,thefollowingfivedefinitionsarebrieflydiscussedhere:
CAMuseincludingallvitamins/mineralsusedinthepast12months
MostInclusive
CAM use including use of specific vitamins/minerals and/or multivitamins
and/ormineralcombinationsandvitaminpacketsusedforspecificconditions
inthepast30days
CAM use including use of specific vitamins/minerals in the past 30 days,
excludingmultivitaminand/ormineralcombinationsandvitaminpackets
CAM use including vitamins/minerals used to treat specific conditions in the
past30days
CAMuseexcludingallvitamins/minerals
LeastInclusive
10
PrevalenceofCAMusevarieswidelyaccordingtothedefinitionofCAMused.TheCAMusedefinition
thatincludesallvitamins/mineralsyieldsfarhigherprevalenceratesthantheotherfourCAMdefinitions
regarding vitamin/mineral use (Table 5). Additionally, associations between CAM use and childrens
demographic characteristics, health status and medical care utilization substantially differ when the
definition includes all vitamin/minerals compared to other CAM use definitions with more restrictive
vitamins/mineralsinclusioncriteria(Tables5and6).Regardlessofthetypeandtreatmentofvitamins
andmineralsuse,theagedistributiondoesnotvarywhenallvitamins/mineralsareincluded.However,
restricted definitions that only include specific groups of vitamins and minerals (e.g. use of specific
vitamins/mineralsoruseforspecifichealthconditions)resultindisproportionatelyhigherprevalenceof
CAMuseamongadolescentsage1217years(Table5).
Demographic and health related characteristics of children who used CAM excluding all
vitamins/minerals are identical with CAM users including vitamins/minerals used to treat specific
conditions (Tables 5 and 6). This may be due to the small number of children whose parents only
reporteduseofvitamins/mineralstotreatspecificconditions(2.3percentofvitamins/mineralsusersin
thepast30days).WhenexcludingtheuseofallvitaminsandmineralsprevalenceofCAMuseislower
amongchildrenwithspecifictypesofconditions(e.g.emotional,mentalorbehavioral(EMB)andpain
related) or complex health problems (CCCESUN and children with >2 chronic conditions) than the
prevalence when using the other more restricted definitions of CAM use, particularly the definition
includingspecificvitamins/mineralsusedinthepast30days(Table7).Interestingly,thesamepatternof
resultswasobservedforconventionalmedicalcareutilizationandaccessproblems.
Childrenwhoseparentsreportedvitamin/mineraluseforspecificconditionsONLYgenerallyhavemore
complexhealthproblems.Thisresultsinahigherprevalenceofchildrenwithsevereproblemswhoused
CAM. For example, the prevalence of CCCESUN is nearly two times higher among children who used
vitamins/minerals for specific conditions ONLY than those who used vitamins in the past 12 months
ONLYandthosewhousedspecificvitamins/mineralsinthepast30daysONLY(Table8).Furthermore,
ofthe12.9percentofchildrenwhousedCAMincludingvitamins/mineralsusedforspecificconditionsin
thepast30days,half(50.5 percent) of parents did not report any health problem or condition as a
reason for CAM use. However, 88.3 percent of these children experienced one or more health
problemsorconditions,andover64.9percentexperiencedthreeormoreofthe59conditionsasked
aboutintheSampleChildCore.
Since nearly all (95 percent) of children who used vitamins/minerals in the past 30 days also used
multivitamin/mineral combinations or vitamins packets, demographic characteristics of these children
were similar to children who used only vitamins/minerals in past 12 months (Table 8). Although
demographics, health status and health care utilization characteristics vary between specific types of
vitaminusers,overallcharacteristicsofCAMusers,whenspecificvitamins/mineralsincludedintheCAM
usedefinition,donotsubstantiallydifferwhenotherCAMusedefinitionsthathaverestrictedinclusion
ofvitamins/mineralsareused.Thus,includingspecificvitamins/minerals(excludingmultivitaminand/or
mineralcombinationsandvitaminpackets)intheCAMusedefinitionmaybewarranted.
11
Table5.DemographicCharacteristicsofChildren,byCAMUseDefinitions,DataSource:2007NHIS
Characteristics
Allchildren
(n=9417)
CAMuseincludingall
vitamins/minerals
(VM)usedinpast12
months(n=4140)
CAMuseincluding
specificVM*usedin
past30dayswith
otherCAMmodalities
inpast12months
(n=1285)
Overallprevalence
100%
47.5%
14.6%
Age
05years(n=3284)
33.7%
31.9%
22.3%
611years(n=2802)
32.1%
35.9%
30.1%
1217years(n=3331)
34.2%
32.2%
47.6%
Sex
Male(n=4865)
51.1%
50.2%
49.0%
Female(n=4552)
48.9%
49.8%
51.0%
Race
Hispanic(n=2870)
20.8%
15.8%
14.0%
White,nonHispanic(n=4197)
56.7%
65.2%
69.4%
Black,nonHispanic(n=1545)
14.7%
11.3%
8.1%
Asian,nonHispanic(n=462)
3.8%
3.9%
3.6%
Multi/other,NonHispanic(n=343)
3.9%
3.7%
4.9%
Income
099%FPL(n=1747)
18.3%
12.0%
10.3%
100199%FPL(n=2288)
24.3%
21.3%
20.9%
200399FPL(n=2817)
31.0%
33.5%
34.5%
400%oraboveFPL(n=2565)
26.4%
33.2%
34.3%
Region
Northeast(n=1616)
16.8%
17.7%
17.2%
Midwest(n=1862)
23.7%
26.2%
26.4%
South(n=3548)
36.9%
34.3%
28.1%
West(n=2391)
22.7%
21.9%
28.3%
Maternaleducation
Lessthanhighschool(n=1672)
16.1%
9.4%
8.4%
HighschoolorGED(n=2207)
25.0%
20.7%
19.6%
Morethanhighschool(n=4770)
58.9%
69.9%
72.0%
*Doesnotincludemultivitaminand/orothermineralcombinationANDvitaminpackets
CAMuseincludingVM
usedforspecific
conditionsinpast30
dayswithotherCAM
modalitiesinpast12
months(n=1133)
CAMuseincludingall
specificVM*and/or
multivitamins/mineral
combinations/vitamin
packetsusedforspecific
conditionsinpast30
days(n=1315)
CAMuse,
EXCLUDINGallVM
(n=1055)
12.9%
14.9%
12.0%
22.6%
29.3%
48.1%
22.5%
29.9%
47.7%
49.2%
50.8%
14.0%
68.9%
8.6%
3.6%
4.9%
10.6%
21.0%
34.5%
33.9%
17.2%
26.5%
28.4%
27.9%
8.6%
19.6%
71.8%
22.4%
29.8%
47.7%
48.8%
51.2%
13.7%
70.0%
8.2%
2.9%
5.2%
10.4%
20.5%
34.6%
34.5%
17.3%
26.8%
28.2%
27.6%
7.8%
19.3%
72.9%
48.3%
51.7%
13.6%
70.5%
7.4%
3.1%
5.4%
10.1%
19.1%
34.8%
36.0%
18.0%
27.3%
27.1%
27.6%
7.3%
18.2%
74.5%
UsingtheNationalHealthInterviewSurveyandMedicalExpendituresPanelSurveytoAssesstheUseandimpactofComplementaryandAlternativeMedicineforChildrenintheUS:AMetaData
MethodsKeyIssuesReport.2013.
12
Table6.ChildrensHealthStatus,InsuranceTypeandHealthCareUtilizationandAccess,byCAMUseDefinitions,Datasource:2007NHIS
Characteristics
CCCESUNstatus
NonCCCESUN(n=7436)
CCCESUN(n=1981)
Conditionstypes/conditions
Emotional,mental,behavioral
problems(EMB)1(n=1307)
Painrelatedconditions2(n=1084)
Depression(n=195)
Backorneckpain(n=311)
Numberofchronicconditions
Nochroniccondition(n=4515)
1chroniccondition(n=2145)
2+chronicconditions(n=2757)
Insurancetype
Publicinsurance(n=2772)
Privateinsurance(n=5666)
Uninsured(n=935)
Numberofofficevisits
03visits(n=6432)
47visits(n=2040)
8ormoreofficevisits(n=793)
Emergencyroomvisits(ER)
NoERvisits(n=7453)
1ERvisit(n=1201)
2+ERvisits(n=688)
Problemsaccessingcare*(n=1572)
RegularlytakeRxmedicationsfor3+
months(n=1088)
Receivedspecialistcare(n=1183)
CAMuse,includingall
vitamins/minerals
(VM)usedinpast12
months(n=4140)
CAMuse,including
specificVM**usedin
past30days,other
CAMmodalitiesin
past12months
(n=1285)
CAMuse,including
VMusedforspecific
conditionsinpast30
days,otherCAM
modalitiesinpast12
months(n=1133)
77.9%
22.1%
72.5%
27.5%
63.8%
36.2%
61.2%
38.8%
CAMuseincluding
specificVMand/or
multivitamins/
mineralcombinations/
vitaminpacketsusedfor
specificconditionsin
past30days(n=1315)
63.4%
36.6%
16.5%
19.5%
29.8%
32.2%
29.7%
33.0%
12.1%
3.0%
3.4%
46.9%
23.3%
29.8%
28.2%
63.1%
8.7%
69.2%
22.1%
8.7%
79.8%
12.9%
7.3%
16.1%
15.8%
3.4%
4.6%
39.3%
23.8%
36.9%
21.7%
71.4%
6.9%
64.2%
24.5%
11.3%
78.7%
14.0%
7.3%
18.2%
23.4%
6.1%
8.5%
28.9%
22.0%
49.0%
20.9%
71.4%
7.7%
58.9%
25.3%
15.8%
75.0%
17.4%
7.7%
23.1%
25.2%
6.9%
9.6%
25.0%
22.7%
52.3%
20.9%
71.2%
7.9%
56.9%
25.5%
17.6%
73.9%
17.9%
8.2%
24.7%
23.3%
6.1%
8.4%
28.7%
22.0%
49.3%
21.1%
71.2%
7.7%
58.5%
25.3%
16.1%
74.3%
17.5%
8.1%
23.5%
25.1%
7.2%
9.6%
25.8%
22.4%
51.7%
19.5%
72.5%
7.9%
56.9%
25.9%
17.2%
75.0%
17.6%
7.3%
23.8%
12.3%
15.3%
22.3%
23.4%
22.4%
23.1%
13.2%
16.5%
21.5%
23.3%
21.9%
23.0%
Allchildren
(n=9417)
CAMuse,
EXCLUDINGallVM
(n=1055)
61.6%
38.4%
*delayand/orunmetneed**Doesnotincludemultivitaminand/orothermineralcombinationANDvitaminpacket EMBcondition/problems:anxiety/stress,depression,ADD/ADHD,phobiaorfears,insomniaortrouble
2
sleeping,incontinenceincludingbedwetting painrelatedconditions/problems:frequentorsevereheadaches,includingmigraine,recurringheadache,otherthanmigraine,arthritis,abdominalpain,backorneckpain,
otherchronicpain
13
Table7.PrevalenceofCAMUse,byChildrensHealthStatus,InsuranceType,HealthCareUtilizationandAccess,DataSource:2007NHIS
Characteristics
CCCESUNstatus
NonCCCESUN(n=7436)
CCCESUN(n=1981)
Conditionstypes/conditions
Emotional,mental,behavioral
problems(EMB)1(n=1307)
Painrelatedconditions2(n=1084)
Depression(n=195)
Numberofchronicconditions
Nochroniccondition(n=4515)
1chroniccondition(n=2145)
2+chronicconditions(n=2757)
Insurancetype
Publicinsurance(n=2772)
Privateinsurance(n=5666)
Uninsured(n=935)
Numberofofficevisits
03visits(n=6432)
47visits(n=2040)
8ormoreofficevisits(n=793)
Emergencyroomvisits(ER)
NoERvisits(n=7453)
1ERvisit(n=1201)
2+ERvisits(n=688)
Problemsaccessingcare*(n=1572)
RegularlytakeRxmedicationsfor3+
months(n=1088)
Receivedspecialistcare
CAMuse,including
allvitamins/minerals
(VM)usedinpast12
months(n=4140)
CAMuse,including
specificVM**usedin
past30days,otherCAM
modalitiesinpast12
months(n=1285)
44.3%
58.9%
11.9%
23.8%
59.6%
CAMuse,includingVM
usedforspecific
conditionsinpast30
days,otherCAM
modalitiesinpast12
months(n=1133)
10.1%
22.5%
CAMuseincludingspecific
VMand/ormultivitamins/
mineralcombinations/
vitaminpacketsusedfor
specificconditionsinpast
30days(n=1315)
12.1%
24.6%
CAMuse,
EXCLUDINGallVM
(n=1055)
9.5%
20.8%
27.7%
26.5%
28.2%
25.4%
61.6%
57.0%
63.3%
39.9%
48.5%
58.6%
36.7%
53.9%
37.6%
44.1%
52.8%
61.6%
46.9%
51.3%
47.9%
53.2%
27.9%
33.3%
36.1%
9.0%
13.8%
23.9%
10.8%
16.5%
12.9%
12.4%
16.7%
26.4%
13.7%
19.6%
15.4%
20.7%
26.6%
33.0%
36.0%
6.9%
12.5%
22.5%
9.6%
14.6%
11.7%
10.6%
14.9%
26.0%
12.0%
17.9%
14.6%
19.6%
28.4%
34.0%
36.2%
9.1%
14.1%
24.5%
11.2%
16.9%
13.0%
12.6%
17.1%
27.5%
13.9%
20.2%
16.7%
21.5%
24.7%
32.4%
33.4%
6.6%
11.6%
20.7%
8.3%
13.8%
10.9%
9.9%
14.1%
23.5%
11.3%
16.4%
12.1%
17.6%
58.6%
26.3%
24.4%
27.0%
22.4%
59.8%
23.8%
22.9%
24.7%
21.0%
*delayand/orunmetneed**Doesnotincludemultivitaminand/orothermineralcombinationANDvitaminpacket EMBcondition/problems:anxiety/stress,depression,ADD/ADHD,phobiaorfears,insomniaortrouble
2
sleeping,incontinenceincludingbedwetting painrelatedconditions/problems:frequentorsevereheadaches,includingmigraine,recurringheadache,otherthanmigraine,arthritis,abdominalpain,backorneckpain,
otherchronicpain
14
Table8.DemographicCharacteristics,HealthStatusandMedicalCareUtilizationofChildren,byStatusofVitamins/MineralsUse
ONLY SPECIFIC
vitamins/mineralsused
Any
inthepast30days,not
vitamins/minerals
including
inthepast30days,
multivitamin/mineral
amongwhoused combinationsandvitamin
inthepast12
packets,nootherCAM
months(n=3119)
modalities,amongwho
usedinthepast30days
(n=129)
84.6%
3.6%
34.1%
27.2%
37.3%
20.5%
28.6%
52.4%
ONLYMultivitamins
and/ormineral
combinationsor
vitaminpacketsinthe
past30days,not
includingspecific
vitamins/minerals,no
otherCAMmodalities,
amongwhouseinthe
past30days(n=2353)
75.1%
ONLY
vitamins/mineral
susedforspecific
conditionsinthe
past30days,no
otherCAM
modalities,
amongwhoused
inthepast30
days(n=78)
2.5%
38.3%
38.1%
23.6%
25.2%
21.9%
52.9%
Characteristics
Any
vitamins/min
eralsinthe
past12
months
n=3713
ONLY
vitamins/mineral
sinthepast12
months,noother
CAMmodalities,
n=3085
Overall
Age
05years
611years
1217years
Familyincome
099%FPL
100199%FPL
200399%FPL
400%FPLorabove
ChildrenwithEMBconditions1
Childrenwithpainrelatedcondition2
43.3%,
32.5%
37.3%
30.2%
11.6%
20.6%
33.8%
33.9%
17.9%
15.0%
35.7%
12.6%
22.0%
33.1%
32.3%
15.0%
12.7%
10.9%
20.5%
33.5%
35.1%
17.4%
14.5%
12.2%
30.3%
38.0%
19.5%
17.3%
18.3%
11.6%
21.4%
32.8%
34.1%
14.4%
11.7%
14.4%
39.5%
30.8%
15.3%
20.6%
26.7%
Childrenwithchronicconditionand
elevatedserviceuseorneed
Anychronicornonchroniccondition
(from59conditions)
Anychroniccondition(from46
possiblechronicconditions)
Missed11ormoreschooldays
TakeRxmedicationfor3+months
1+emergencyroomvisit
Receivedspecialistcare
Problemsaccessingcare*
26.3%
23.8%
26.7%
22.2%
23.8%
42.8%
84.8%
83.0%
84.6%
78.6%
82.6%
99.0%
59.5%
56.2%
59.3%
52.7%
55.9%
86.4%
4.5%
14.4%
20.5%
15.7%
17.8%
3.4%
12.6%
20.1%
14.3%
16.3%
4.0%
14.9%
20.3%
15.4%
16.9%
3.7%
13.0%
25.2%
11.9%
22.7%
2.7%
12.3%
19.6%
14.0%
14.8%
12.1%(n=9)
27.8%
41.8%
27.5%
37.4%
35.1%
37.9%
27.0%
*Delayand/orunmetneed1EMBcondition/problems:anxiety/stress,depression,ADD/ADHD,phobiaorfears,insomniaortroublesleeping,incontinenceincludingbedwetting2painrelated
conditions/problems:frequentorsevereheadaches,includingmigraine,recurringheadache,otherthanmigraine,arthritis,abdominalpain,backorneckpain,otherchronicpain
15
DiscordancebetweenConditionsReportedversusConditionsNamedas
theReasonforCAMUseAmongChildren
OverviewoftheConditionsaskedaboutintheSampleChildCoreversusConditionsNamed
astheReasonforCAMUseintheChildCAMSupplement
ConditionschildrenexperiencedthatwereaskedaboutintheSampleChildCore:
59conditionschildrenexperiencedeverorinpast12month:
57specificconditionsaresametothoseaskedinChildCAMSupplement
2additionalconditions:verylowbirthweight(children<2years)andlearning
disability
ConditionsparentnamedasreasonforCAMuseintheChildCAMSupplement:
59conditionsCAMwasusedtotreatspecificconditions
57specificconditionsaresametothoseaskedinSampleChildCore
2additionalconditions:musculoskeletal(backcoded)andotherspecify
EvidenceofvalidityissuesemergedwithrespecttotheNHISCAMSupplementmethodofaskingabout
the conditions or problems CAM was used to treat (following each of 17 CAM modalities; some
modalitiesaregroupedtogether).The parentsofmanychildren includedin the2007surveyreported
thattheirchildwasusingCAMtotreataconditionintheCAMSupplementthattheydidnotpreviously
reportthechildhadexperiencedeverorinthepast12monthsintheSampleChildFile.Forexample,47
percent of parents reporting CAM use for back or neck pain DID NOT report this as a problem in the
Sample Child file (Table 9). Use of CAM to treat specific conditions may be underreported, because
childrenuseCAMforreasonsthatarenotdirectlytiedtoaparticularhealthconditionorproblem,but
ratheroverallwellbeingorconditions,symptomsorproblemsthatarecrosscutting.Parentsreporting
their childrens CAM use may consequently have difficulty attributing a specific CAM modality to a
specific condition. Among the 14.6 percent of children who used CAM, including specific
vitamins/mineralsinpast30days,overhalf(51.8%)ofparentsDIDNOTreportanyhealthproblemor
condition as a reason for CAM use, according to the 2007 NHIS. Yet, 88.3 percent of these same
children experienced one or more condition(s), and nearly twothirds (64.9%) experienced three or
moreofthe59healthproblemsandconditionsassessedintheNHISSampleChildFile.
Itispossiblethatparentswerelessinclinedtonamespecificconditionsasthereasonfortheirchildrens
CAMuse,becausechildrenusedCAMforoverallhealthandwellbeingorforspecificfunctionalissues
versusmorediscretediagnoses.Nearly9in10(86.0%)oftraditionalhealerusers,60.9%ofacupuncture
usersand42.0%chiropractic/osteopathicmanipulationusersDIDNOTnameanyconditionsintheChild
CAM Supplement. However, 77.3%, 84.8% and 88.4% of children who used these therapies,
respectively,didreportaconditionintheSampleChildCore(Table10).
16
Table9.ChildrenwithCAMUse1whohadConcordantConditionsbetweentheSampleChildCoreand
theChildCAMSupplement(MostPrevalentConditionsorProblems)
Conditions
(AmongChildrenfromthe
SampleChildCore)
Autism(n=58)
Depression(417years)
(n=195)
Food/digestiveallergies
(n=378)
Nonstrep,sorethroat
(n=2808)
Insomnia/troublesleeping
(317years)(n=387)
ADD/ADHD(n=540)
Headorchestcold
(n=4456)
Allergiesotherthanhay
fever/food/
respiratory/skinallergies/
eczema(n=451)
Anxietyorstress(n=538)
Anemia(n=121)
Asthmawithepisodesin
past12months(n=485)
Amongchildrenwhose
parentsnamedthecondition
inSampleChildCore,%who
usedCAM1
Amongchildrenwhoseparents
namedtheconditioninSample
ChildCoreandusedCAM,%
whoreportedconditioninChild
CAMSupplementasreasonfor
CAMuse
n
%
6
26.6%
21
28.2%
n
21
75
%
34.7%
33.3%
96
25.5%
11
571
20.8%
129
Amongthosereporting
conditionasreasonfor
CAMuse,the%who
reportedsameconditionin
SampleChildCore
n
6
21
%
100
100
12.4%
11
100
17
4.2%
17
98.0
32.0%
17
14.9%
17
89.9
140
779
25.3%
17.9%
33
65
23.7%
11.3%
33
65
88.4
88.3
97
20.6%
11
16.6%
11
86.9
205
32
94
37.4%
32.2%
20.2%
48
25
13
26.1%
69.0%
16.9%
48
25
13
85.2
66.8
63.9
120
36.1%
50
42.0%
50
52.7
ThisCAMusedefinitionincludesspecificvitamins/mineralsusedinpast30days. Shadedcellsdonotmeetstandardsofprecision(RSE>30).
Table10.RelationshipBetweenConditions/ProblemsReportedintheSampleChildandChildCAM
Files(MostPrevalentCAMModalities
CAMmodalities
(Totalnumberofchildrenwhousedeach)
Traditionalhealers*(n=95)
Acupuncture(n=22)
Relaxationtechniques**(n=254)
Naturopathy(n=25)
Herbalsupplementsinpast30days(n=170)
Chiropractic/osteopathicmanipulation(n=220)
Homeopathy(n=96)
AmongwhousedtheCAM
modality,%namedconditionsin
SampleChildFile(59conditions)
n
W%
73
77.3%
19
84.8%
244
93.5%
21
85.5%
303
93.7%
202
88.4%
90
88.3%
AmongwhousedCAMmodality,%
DIDNOTnameconditionsinChild
CAMFileasreasonforCAMuse
n
W%
77
86.0%
13
60.9%
145
56.1%
11
54.1%
87
52.9%
77
42.0%
16
11.8%
TraditionalhealersdefinitionincludesCurandero,Espiritista,HierberoorYerbera,Shaman,Botanica,Medicineman,andSobador
Relaxationtechniquesincludes:meditation,guidedimagery,progressiverelaxation,supportgroupmeeting,andstressmanagementclass
**
17
CapacitytoIdentifyChildrenwithSpecialHealthCareNeeds
The identification of children with special health care needs (CSHCN) is an ongoing need for Federal,
Stateandlocalhealthagencies,healthplans,providersandconsumerorganizations.TheMaternaland
Child Health Bureau (MCHB)definesCSHCNas:thosewhohave orareatincreasedriskfora 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.14 The validated CSHCN
Screener10,15,16 operationalizes the MCHB definition of CSHCN and it is widely used in several national
surveys,suchasMEPS.TheScreeneriseasytoadminister,takinganaverageoflessthantwominutesto
complete. The NHIS does not contain a standardized screener that identifies children with ongoing
health conditions or problems based on service use and access rather than by specific conditions.
Identifying CSHCN using the Screener in the NHIS or CAM supplement would extend data use
capabilitiesandprovidebroaderapplicabilitywithrespecttoothernationaldatasourcesemployingthe
CSHCNScreener.
An algorithm was developed to identify children with chronic conditions and elevated service use
(CCCESUN).17,18 This algorithm is based on 20 consequencesoriented survey items and 38 conditions
askedaboutinthe2007NHIS.Thealgorithmisusedtoidentifychildrensimilartothoseidentifiedbythe
CSHCNScreener.SincethisalgorithmisonlyanapproximationoftheCSHCNScreener,CCCESUNisused
to describe the subpopulation of children identified rather than CSHCN. The prevalence of children
identifiedbytheNHISCCCESUNalgorithmandtheMEPSCSHCNScreenerissimilar(Figure2).
However,only56percentofchildrenidentifiedwiththeCCCESUNalgorithmmettheCSHCNScreener
criteria in the linked NHIS/MEPS file. Children identified by the CCCESUN algorithm differ from those
identified by the CSHCN Screener in terms of demographic and other characteristics (Table 11).
Conceptually similar qualifying criteria categories as measured by the CSHCN Screener were used to
categorizethoseidentifiedwiththeCCCESUNalgorithm.Thedistributionacrossthesecategoriesforthe
CCCESUN algorithm differs from the CSHCN Screener (Table 12). Most importantly, the proportion of
CCCESUNmeetingthequalifyingcriteriaalsodiffersfrompercentestimatesofCSHCNinthe2008MEPS,
2009/10 National Survey of Children with Special Health Care Needs (NSCSHCN) and 2007 National
SurveyofChildrensHealth(NSCH)qualifyingforthecriteria(highlightedingreeninTable13),whilethe
latterthreesurveyestimatesarenearlyidentical.
The NHIS CCCESUN method yielded a variable that was less robust than the CSHCN Screener for
identifying children with an ongoing health condition for which they need or use health or related
services of a type or amount greater than children generally. Children identified by both instruments
hadagreaterlikelihoodofmissingtwoormoreweeksofschoolcomparedtochildrenonlyidentifiedby
the CCCESUN algorithm (Table 11). Children meeting the CCCESUN algorithm but not the CSHCN
Screenerhaveadifferenthealthconditionandconditionseverityprofile;generallyreflectinglessimpact
andseveritythanchildrenidentifiedwithbothinstruments.Forexample,9.1percentofCCCESUNhad
asthmawithanattackinthepast12monthscomparedto19.1percentofCCCESUNwhoalsometthe
CSHCN Screener criteria (Table 16). The number of chronic conditions that a child experienced also
varied between children identified by both the CCCESUN algorithm and the CSHCN Screener and
children only identified by the CCCESUN algorithm. For instance, children identified by both methods
were more likely to experience four or more conditions than children only identified by the CCCESUN
algorithm.
18
While the CCCESUN algorithm is based upon conditions and specific types of service use, it does not
havetheabilitytoevaluatewhetherornotCCCESUNaremorelikelytohavecertaintypesofconditions
orusecertainamounts(e.g.numberofvisits)ortypesofservices(e.g.mentalhealthcare)thanother
children.Bycontrast,theCSHCNScreenerisnotconditionspecificanddoesnotqueryindetailabout
specificservicesused.
The absence of a standard CSHCN measurement method across the national surveys restricts valid,
robust analyses of CSHCN health and health related issues, as well as disparities between CSHCN
subgroups.Thus,includingtheCSHCNScreenerwithintheNHISoritsCAMsupplementwouldimprove
theutilityofresultantdata,additionallyaligningCSHCNdatadirectlywiththatintheMEPS.
Figure2.PrevalenceofCAM*UseinDifferentDataSets,byCCCESUNandCSHCNStatus
p=.65
30%
25%
p=.78
25.1%
23.8%
24.7%
CCCESUN/CSHCNPrevalence:
2007NHISCCCESUN:22.1%n=1981
2008MEPSCSHCN:18.4%n=1541
NHIS/MEPS(CCCESUNinNHIS):23.0%n=518
NHIS/MEPS(CSHCNinMEPS):21.4%n=414
20%
14.3%
15%
11.9%
11.6%
10%
5%
0%
CCCESUN/CSHCN
2007NHIS
NHIS/MEPS(CCCESUNinNHIS)
NonCCCESUN/NonCSHCN
NHIS/MEPS(CSHCNinMEPS)
*TheCAMusedefinitionusedforthisanalysisincludes39typesofCAMmodalitiesincludingspecific
vitamins/mineralsusedinthepast30days.
19
Table11.Demographic,HealthandHealthCareRelatedCharacteristicsofChildrenWhoMetBoththeCCCESUNAlgorithm
(NHIS)andtheCSHCNScreenerCriteria(MEPS)andPositivelyIdentifiedbyEitherCCSESUNAlgorithmOnlyorCSHCN
ScreenerinMEPSDatasources:NHISandMEPSLinkedFile
CharacteristicsinNHIS
Childrenwhometboth
CSHCNScreenerand
CCCESUNAlgorithmcriteria
n
%
Demographiccharacteristics
Age
05years
55
611years
98
1217years
84
Sex
Male
158
Female
79
Race
Hispanic
57
White,nonHispanic
106
Black,nonHispanic
51
Asian,nonHispanic
3
Multi/other,NonHispanic
20
FamilyIncome(FederalPovertyLevelFPL)
099%FPL
61
100199%FPL
67
200399FPL
58
400%oraboveFPL
51
USRegion
Northeast
51
Midwest
57
South
92
West
37
Maternaleducation
Lessthanhighschool
29
HighschoolorGED
59
Morethanhighschool
127
Healthandhealthcarerelatedcharacteristics
Insurancetype
Publicinsurance
94
Privateinsurance
133
Uninsured
10
Missedschooldays(517years)
Missed11ormoreschooldays
26
Missed010schooldays
160
Emergencyroomvisits
1emergencyroomvisit
37
2ormoreemergencyroomvisits
43
Problemsaccessingconventionalcare(delay/unmet)
1ormoreproblem
70
CAMuse(includesspecificvitamins/mineralsusedinthepast30days)
Used1ormoreCAM
64
NumberofCAM
1typeofCAM
38
2typesofCAM
16
3ormoretypesofCAM
10
CAMtypes
11
AlternativeMedicalSystem/EnergyHealing
Biologicallybasedtherapies
32
Manipulativeandbodybasedtherapies
14
Mindbodytherapies
31
CCCESUNinNHISnon
CSHCNinMEPS
n
p=0.08
21.9%
40.7%
37.4%
82
69
61
33.5%
38.4%
28.0%
108
104
47.7%
52.3%
88
72
41
4
7
24.3%
58.4%
13.4%
0.8%
3.1%
77
52
50
33
25.7%
18.8%
30.3%
25.2%
25
50
83
54
11.6%
29.3%
34.3%
24.8%
51
56
92
16.0%
28.9%
55.1%
34.2%
62.6%
3.2%
88
93
31
31.6%
56.3%
12.1%
12.6%
87.4%
13
128
7.9%
92.1%
34
31
13.9%
10.8%
30.1%
78
36.3%
31.9%
40
25.8%
52.1%
33.4%
14.5%
20
14
6
37.1%
44.8%
18.1%
6.0%
17.4%
7.8%
13.9%
10
20
15
12
4.0%
11.6%
13.5%
11.3%
p=0.004
65.7%
34.3%
p=0.08
14.5%
63.6%
13.6%
0.6%
7.7%
p=0.49
19.8%
24.3%
27.5%
28.5%
p=0.03
21.5%
26.7%
39.3%
12.4%
p=0.1
9.3%
24.3%
66.4%
p=0.02
p=0.38
13.3%
15.6%
p=0.29
NonCCCSESNinNHIS
CSHCNinMEPS
n
66
56
55
91
86
47
67
48
6
9
41
47
52
37
36
36
68
37
28
48
92
69
96
11
7
113
29
9
27
22
22
0
0
2
9
8
3
30.6%
41.0%
28.4%
45.3%
54.7%
15.0%
57.2%
17.1%
3.7%
7.0%
14.5%
28.1%
30.7%
26.8%
19.8%
25.7%
38.3%
16.2%
9.3%
31.0%
59.7%
27.4%
65.4%
7.2%
5.0%
95.0%
15.2%
6.3%
15.6%
13.8%
100.0%
1.2%
5.0%
5.6%
2.0%
Shadedcellsdonotmeetstandardsofprecision(relativestandarderrorisgreaterthan30%)
20
Table12.CCCESUNIdentifiedbytheCCCESUNAlgorithminNHISandCSHCNIdentifiedbytheCSHCNScreenerinMEPSMettheQualifyingCriteria
ConditionSetsandQualifyingCriteria
Conditions(notnecessaryconsequences)
Parentreportedconditions
Conditionstoldbyhealthprofessionals
Conditionstoldbyhealthprofessionals+VLBW(limitedconditionset)
Conditionstoldbyhealthprofessionals+parentreported+VLBW(comprehensiveconditionset)
NHISAlgorithmqualifyingcriteria(with/withoutconditionsets)
ConsequencesqualifyingcriteriaONLY(notcrossedwithconditions)
Qualifiedonprescriptionmedicineuseorneed(consequencesqualifyingcriteriaONLY)
Qualifiedonelevatedserviceuseorneeds(consequencesqualifyingcriteriaONLY)
Qualifiedonfunctionallimitations(consequencesqualifyingcriteriaONLY)
Qualifiedonuseofspecialtherapies(consequencesqualifyingcriteriaONLY)
QualifiedonongoingEDBconditions(consequencesqualifyingcriteriaONLY)
Consequencesqualifyingcriteria+limitedconditionset
Qualifiedonprescriptionmedicineuseorneed(consequences+limitedconditionset)
Qualifiedonelevatedserviceuseorneeds(consequences+limitedconditionset)
Qualifiedonfunctionallimitations(consequences+limitedconditionset)
Qualifiedonuseofspecialtherapies(consequences+limitedconditionset)
QualifiedonongoingEDBconditions(consequences+limitedconditionset)
Consequencesqualifyingcriteria+comprehensiveconditionsetFINALCCCESUN
Qualifiedonprescriptionmedicineuseorneed(consequences+comprehensiveconditionset)
Qualifiedonelevatedserviceuseorneeds(consequences+comprehensiveconditionset)
Qualifiedonfunctionallimitations(consequences+comprehensiveconditionset)
Qualifiedonuseofspecialtherapies(consequences+comprehensiveconditionset)
QualifiedonongoingEDBconditions(consequences+comprehensiveconditionset)
CCCESUNinNHIS
CSHCNinMEPS
(NHISonly)(n=1981)* (linkedfile)n=414**
n
%
n
%
1605
81.5%
241
60.4%
1276
63.9%
218
54.4%
1282
64.1%
219
54.5%
1981
100.0%
310
76.3%
1981
100.0%
267
67.4%
1090
54.8%
172
43.8%
1073
53.9%
150
38.7%
243
11.9%
46
11.4%
353
19.1%
63
15.0%
630
32.4%
101
26.3%
1282
64.1%
186
47.3%
751
37.4%
130
33.5%
758
38.1%
116
30.4%
201
9.8%
40
9.9%
264
13.6%
48
10.9%
493
25.6%
85
22.4%
1981
100.0%
237
59.9%
1090
54.8%
159
40.4%
1073
53.9%
134
34.7%
243
11.9%
44
11.0%
353
19.1%
56
13.3%
630
32.4%
100
26.1%
EDBemotional,developmentalorbehavioral*WeightedbytheNHISSamplechildweights**WeightedbytheNHIS/MEPSlinkedfileweights
Table13.ChildrenWhoMetQualifyingCriteria,SurveyComparison
MEPSCSHCNScreenerCriteria
Qualifiedonprescriptionmedicineuseorneed
Qualifiedonelevatedserviceuseorneeds
Qualifiedonfunctionallimitations
Qualifiedonuseofspecialtherapies
Qualifiedonongoingemotional,developmentalorbehavioralconditions
2007NHIS**
(metbothcriteria)
162
70.4%
105
45.2%
73
28.1%
55
24.0%
88
36.4%
2008MEPSOnly*** 2009/10 2007NSCH

(n=1541)
NSCSHCN
1104
74.5%
76.0%
76.4%
599
39.0%
42.1%
43.8%
356
22.4%
23.5%
22.6%
305
18.5%
21.5%
18.5%
465
29.5%
31.8%
30.6%
21
**WeightedbytheNHIS/MEPSlinkedfileweights***WeightedbyMEPSPersonweightsNote:MEPS,NSCSHCNandNSCHusedtheCSHCNScreener
Table14.ChildrenWhoMetBoththeNHISAlgorithmandtheCSHCNScreenerCriteria(MEPS)andPositivelyIdentifiedbyEithertheCCCESUNAlgorithmOnlyortheCSHCN
ScreenerinMEPSMetQualifyingCriteria,DataSources:2007NHIS,2008MEPSandNHIS/MEPSLinkedFile
MetbothMEPS
Didnotmeetboth
CCCESUNinNHIS NonCCCESUNin
CSHCNScreenerand
MEPSCSHCN
nonCSHCNin
NHISCSHCNin
NHISAlgorithm
ScreenerandNHIS
Qualifyingcriteria
MEPS
MEPS
criteria
Algorithmcriteria
n
%
n
%
n
n%
n
%
NHISAlgorithmqualifyingcriteria
CSHCNidentifiedbyconsequencesqualifyingcriteriaONLY
237
100.0%
212
100.0%
30
18.5%
139
8.3%
159
67.3%
86
43.3%
13
8.6%
34
1.8%
134
57.9%
119
55.3%
16
9.9%
82
4.7%
44
18.4%
16
5.6%
2
0.9%
4
0.3%
56
22.1%
29
15.9%
7
4.4%
16
1.3%
QualifiedonongoingEDBconditions
100
43.5%
51
19.3%
1
0.5%
26
1.5%
ConsequencesQualifyingCriteria+conditionstoldbyhealthprofessionals
186
79.0%
126
56.3%
(limitedconditionset)
130
55.8%
50
21.5%
116
50.7%
73
33.6%
NA
40
16.5%
11
3.6%
48
18.2%
21
10.9%
85
37.3%
37
14.4%
ConsequencesQualifyingCriteria+allconditions(comprehensivecondition
237
100.0%
212
100.0%
set)FINAL
159
67.3%
86
43.3%
134
57.9%
119
55.3%
NA
44
18.4%
16
5.6%
56
22.1%
29
15.9%
100
43.5%
51
19.3%
MEPSCSHCNScreenerqualifyingcriteria
Qualifiedonprescriptionmedicationuse(notonly)
162
70.4%
0
0.0%
121
68.0%
0.00
0.0%
105
45.2%
0
0.0%
57
33.2%
0.00
0.0%
73
28.1%
0
0.0%
22
14.3%
0.00
0.0%
55
24.0%
0
0.0%
18
8.3%
0.00
0.0%
88
36.4%
0
0.0%
32
17.8%
0.00
0.0%
22

Table15.ConsequencesQualifyingCriteriaSurveyItems
QualifyingcriteriasurveyItems
Qualifiedonprescriptionmedicineuseorneed(qualifyingcriteriaONLY)
RegularlytakenRxmedsforatleast3moths
UnmetforRxmeds
Qualifiedonelevatedserviceuseorneeds(qualifyingcriteriaONLY)
Hasanyimpairmentorhealthproblemthatrequirestousespecial
equipment,suchasabrace,awheelchair,orahearingaid(excluding
ordinaryeyeglassesorcorrectiveshoes)
Tenormorevisitstoahealthprofessional,past12months
Hospitalovernighthospitalstayotherthanbirth,past12months
Anyhomecarevisits,past12months
Currentlyreceivesspecialeducationandearlyinterventionservices
UnmetneedforMEDICALCARE,past12months,duetocost
Qualifiedonfunctionallimitations(qualifyingcriteriaONLY)
Limitedinanyway:play(04),walk,rememberandother
Needshelpfromotherswithanypersonalcareneeds,age317
Hasmobilityimpairmentlimitsabilityto(crawl),walk,run,orplaythat
haslastedorexpectedtolast>12months
Hearingabilitywithouthearingaid:Hasalotoftroubleordeaf
Qualifiedonuseofspecialtherapies(qualifyingcriteriaONLY)
Familyhasseenortalkedtophysicaltherapist,speechtherapist,
respiratorytherapist,audiologist,oroccupationaltherapistinpast12
monthsconcerningthehealthofthechild
(qualifyingcriteriaONLY)
Familyhasseenortalkedtomentalhealthprofessionalsuchasa
psychiatrist,psychologist,psychiatricnurse,orclinicalsocialworker
inpast12monthsconcerningthehealthofthechild,217years
Unmetneedformentalhealthcare,past12months,duetocost
Saw/Talkedtoageneraldoctor(adoctoringeneralpractice,pediatrics,
familymedicine,internalmedicine)becauseofemotionalorbehavioral
problemmayhaveduringpast12months
Conditionsets(notnecessaryconsequences)
Parentreportedconditions
Conditionstoldbyhealthprofessionals(limitedconditionset)
Comprehensiveconditionset(healthprofessionals+parentreported)
MetbothMEPSCSHCN
ScreenerandNHIS
Algorithmcriteria
CCCESUNinNHIS
nonCSHCNinMEPS
NonCCCESUNin
NHISCSHCNinMEPS
DidnotmeetbothMEPS
CSHCNScreenerandNHIS
Algorithmcriteria
n
159
151
18
134
%
67.3%
64.3%
4.9%
57.9%
n
86
64
25
119
%
43.3%
33.6%
10.8%
55.3%
n
13
11
2
16
%
8.6%
7.4%
1.3%
9.9%
n
34
16
18
82
%
1.8%
0.8%
0.9%
4.7%
12
5.4%
0.4%
0.3%
0.4%
60
23
9
74
15
44
29
14
27.7%
6.6%
1.9%
31.1%
6.2%
18.4%
13.1%
6.6%
45
20
5
45
27
16
6
1
21.1%
9.1%
2.8%
20.7%
13.0%
5.6%
2.3%
0.1%
6
3
1
4
2
2
0
0
4.0%
1.0%
1.5%
2.0%
1.4%
0.9%
0.0%
0.0%
30
20
1
10
22
4
3
0
1.7%
1.1%
0.03%
0.7%
1.4%
0.3%
0.3%
0.0%
23
9.6%
2.3%
0.3%
0.0%
2
56
0.7%
22.1%
2
29
1.1%
15.9%
1
7
0.6%
4.4%
0
16
0.0%
1.3%
56
22.3%
29
16.0%
4.5%
16
1.3%
100
43.5%
51
19.3%
0.5%
26
1.5%
79
38.3%
32
13.5%
0.6%
14
1.1%
2.9%
4..6%
0.0%
0.2%
52
22.6%
20
6.3%
0.0%
12
0.6%
180
186
237
78.2%
79.0%
100.0%
174
126
212
80.9%
56.3%
100.0%
61
33
73
33.8%
17.9%
40.9%
403.00
114
455
28.1%
8.1%
31.0%
Shadedcellsdonotmeetstandardsofprecision(relativestandarderrorRSEisgreaterthan30%)
23

Table16.PrevalenceofChronicConditionsamongCCCESUNandCSHCN
Numberof
Numberof
Childrenwhomet
childrenin
childrenin
bothMEPSCSHCN
CCCESUNinNHIS
samplechild
NHIS/MEPS
ScreenerandNHIS
nonCSHCNinMEPS
file
linkedfile
Algorithmcriteria
n
n
n
Column%
n
Column%
Arthritis
10
4
2
0.7%
1
0.1%
Migraineheadache(317years)
396
107
24
9.8%
22
11.3%
Recurringnonmigraineheadache(317years)
329
98
27
10.4%
18
11.1%
Foodordigestiveallergy
378
92
24
8.9%
15
6.3%
Frequent/repeateddiarrheaorcolitis
155
57
12
4.2%
16
15.6%
Asthmawithepisodeinpast12months
485
133
57
19.1%
20
9.1%
Hayfever
931
214
46
24.7%
40
22.7%
Respiratoryallergy
856
202
54
25.7%
39
21.9%
Otherlungandbreathingproblem
318
81
22
7.5%
18
6.0%
Otherallergies
451
111
25
12.4%
18
8.8%
3ormoreearinfections
484
134
25
10.4%
25
10.3%
Hearingproblem
329
70
15
7.3%
5
2.0%
Visionproblem
221
62
14
7.0%
5
2.0%
Eczemaorskinallergy
856
228
48
19.9%
34
15.6%
Severeacne
246
62
10
2.7%
9
5.4%
Cancer
8
1
0
Congenitalheartdisease
27
3
1
0.1%
1
0.2%
Cysticfibrosis
1
0
0
Diabetes
17
8
3
0.9%
1
0.4%
Otherheartcondition
94
20
5
1.9%
4
1.7%
Gumdisease
44
9
0
2
0.3%
Anemia
121
34
8
2.7%
7
1.6%
Sicklecellanemia
17
5
0
3
0.4%
Musculardystrophy
3
2
2
0.4%
0
Seizures
67
18
7
2.2%
2
0.5%
Anxietyorstress(417years)
538
142
53
30.2%
37
25.0%
Depression(417years)
195
52
24
11.6%
11
6.8%
ADD/ADHD(217years)
540
147
75
38.6%
29
11.3%
Phobiaorfears(417years)
204
64
24
12.2%
16
10.2%
Autism
58
32
13
5.8%
4
1.1%
Mentalretardation
54
19
11
4.6%
3
1.5%
Otherdevelopmentaldelay
274
87
46
20.7%
19
9.0%
Otherneurologicalproblems
108
32
21
9.5%
4
1.2%
Learningdisability(317years)
557
153
64
33.9%
47
29.0%
Speechproblem(317years)
119
40
10
3.0%
13
5.3%
Otherchronicpain
110
33
7
2.9%
4
2.0%
Fatigueorlackofenergy
293
76
26
11.4%
15
8.3%
Cerebralpalsy(InterviewQ3and4)
11
2
1
0.2%
0
Downsyndrome
12
4
2
0.7%
0
Verylowbirthweight,02years
35
12
3
11.8%
3
8.7%
Recurringconstipation
447
128
29
12.3%
24
7.5%
Problemswithbeingoverweight
540
145
30
11.1%
19
7.9%
Acidrefluxorheartburn
386
96
28
11.6%
8
3.3%
Menstrualproblems
267
80
8
39.6%
7
14.2%
Insomnia(317years)
387
111
42
19.6%
17
9.3%
Bedwetting(417years)
215
61
23
11.9%
7
4.4%
ConditionsevertoldbyahealthprofessionalConditionstoldbyahealthprofessionalduringthepast12months
Conditionevertoldbyschoolorhealthprofessional
46chronicconditionsaskedaboutinthe2007
NHISSampleChildCore
Otherchronic
conditions
ChronicConditionsincludedintheNHISAlgorithm
UsingtheNationalHealthInterviewSurveyandMedicalExpendituresPanelSurveytoAssesstheUseandimpactofComplementaryand
AlternativeMedicineforChildrenintheUS:AMetaDataMethodsKeyIssuesReport.2013.
24
AbilitytoCompareHealthStatus,HealthOutcomesandConventional
MedicalCareUtilizationAcrossTimeforMatchedChildrenWhoUseor
DoNotUseCAM
AssessingimpactofCAMuseintheNHIS/MEPSlinkedfile
The longitudinal nature of the NHIS and MEPS data collection could allow researchers to assess the
impactofCAMuseonchildrenshealthoutcomesandconventionalmedicalcareutilizationforchildren
associatedwiththeirmatchedtimeorfuturereportedyearintheNHIS/MEPSlinkedfile.Thepotential
impactofCAMuseonreductionofemergencyroomutilizationamongchildrenissuggestedbasedon
findings from the 2007 NHIS and 2008 MEPS linked file. Overall, 21.9 percent of children reported to
havehadoneormoreemergencyroom(ER)visit(s)inthe2007NHISmatchedyearofCAMuse(time
1)werealsoreportedtohavehadatleastoneERvisitinthefutureyearinthe2008MEPS(time2).
Children who had an ER visit in time 1 and used CAM were less likely to have had a repeated
emergency room visit in time 2 than children who did not use CAM. This association is especially
pronounced among children with chronic conditions and elevated service use or need (i.e. CCCESUN),
forwhomsignificantlylessERutilizationwasreportedforCCCESUNwhousedCAMthanthosewhodid
notuseCAM(Figure3).AlthoughdifferencesinERutilizationbetweenCAMusersandnonCAMusers
amongsubgroupsofchildrenwithvarioushealthstatuseswere consistent,thestatistical analysiswas
notpreciseenoughtoreportduetosmallsamplesize.
Figure3.UtilizationofEmergencyRoominTime1andFutureYearofCAMUse(Time2),
Datasources:2007NHISandNHIS/MEPSLinkedFile
40%
33.8%
p=0.03
p=0.28
30%
p=0.39
23.0%
20.6%
19.0%
17.6%
20%
14.7%
10%
0%
Allchildren,21.9%
n=121
n=98
n=
AmongCAMusers
AmongCCCESUN,
n=1 n= 29.5%n=51n=1
n=6
Amongnon
n=4 n=1
CCCESUN,18.3%
n=70
AmongnonCAMusers
RSE>30
25
AlignmentofNHISandMEPSSurveyItems
VariabilityofNHISandMEPSsurveyitemswithrespecttowording,referenceperiodandcontentsofthe
items limits the ability to compare utilization of medical care between time 1 and time 2 (Tables
17A,17Band17C).Standardizationofthequestionsaskedacrosssurveyswouldimprovetheabilityto
uselongitudinaldata.
Table17A.SpecialistCare,byCAMUseandCSHCNStatusDataSources:NHISandNHIS/MEPSLinkedFile
2007NHIS
MEPSNHIS/MEPS
SurveyItem
CAU.240_00.000:DURINGTHEPAST12 CS20*:Inthelast12months,didyouor
MONTHS,haveyouseenortalkedtothe adoctorthink(PERSON)neededtosee
followingabout[S.C.name]'shealth?
aspecialist?
Inclusion/exclusio
Amedicaldoctorwhospecializesina
Whenyouanswerthenextquestions,
nofspecialty
particularmedicaldiseaseorproblem
donotincludedentalvisits.Specialists
(otherthanobstetrician/gynecologist, aredoctorslikesurgeons,heartdoctors,
psychiatristorophthalmologist?asked allergydoctors,skindoctors,andothers
separately)
whospecializeinoneareaofhealth
care.
Allchildren
AmongCSHCN
Allchildren
AmongCSHCN
13.2%(n=1183)
30.6%(n=604)
18.0%(n=345)
42.8%(n=163)
AmongCAM
23.3%
39.3%
28.3%
47.7%
users
AOR:1.58
AOR:1.50
AOR:1.39
AOR:1.07
(1.251.98)
(1.082.08)
(0.762.55)
(0.522.18)
AmongnonCAM
11.4%
28.3%
16.3%
41.2%
users
Ref:1.00
Ref:1.00
Ref:1.00
Ref:1.00
Table17B.Hospitalization,byCAMUseandCSHCNStatus,DataSources:NHISandNHIS/MEPSLinkedFile
2007NHIS
MEPSNHIS/MEPS
Survey
FAU.060_00.000[fill1:were
Datausedtoconstructtheinpatient
Item/Description
you/Includingallinfantsbornina
utilizationvariablefornewbornswere
hospital,hasanyoneinthefamily]been
editedtoexcludestayswherethe
newbornleftthehospitalonthesame
hospitalizedOVERNIGHTinthepast12
dayasthemother.However,ifthe
months?Donotincludeanovernightstay
newbornwasdischargedatalaterdate
intheemergencyroom.
thanthemotherwasdischarged,then
thedischargewasconsidereda
separatestayforthenewbornwhen
constructingtheutilizationvariable.
Allchildren
AmongCSHCN
Allchildren
AmongCSHCN
6.0%(n=629)
2.3%(n=57)
(MEPS)
4.0%(n=15)
AmongCAM
4.8%(n=66)
NA:Hospitalstay
2.4%*(n=12)
2.5%*(n=3)
itemisusedto
users
(3.7%notincluding
birth)
identifyCSHCN
AmongnonCAM
6.2%(n=559)
2.3%(n=45)
3.9%*(n=12)
users
(2.5%notincluding
birth)
26
Table17C.HealthOutcome:Missed11orMoreSchoolDays,byCAMuseandCSHCNstatus,DataSources:
2007NHISandNHIS/MEPSLinkedFile
2007 NHIS
MEPS NHIS/MEPS
SurveyItem
CHS.220_00.000:DURINGTHEPAST
DD05:{Includingthetime(PERSON)
12MONTHS,thatis,since[fill1:12
(were/was)inthehospital,how/How}
monthref.date],abouthowmany
manydaysdid(PERSON)missahalfday
daysdid[fill2:S.C.name]miss
ormoreofschool(ordaycare)
{since(STARTDATE)/between(START
schoolbecauseofillnessorinjury?
DATE)and(ENDDATE)becauseofa
physicalillnessorinjury,oramentalor
emotionalproblem.
Age
517years
422yearsconstructedavariable
among517years
Allchildren
AmongCSHCN
Allchildren
AmongCSHCN
4.0%(n=276)
10.1%(n=177)
5.0%(n=69)
12.4%(n=35)
AmongCAMusers
9.6%(n=98)
19.0%(n=78)
5.4%(n=10)
6.9%*(n=5)
AmongnonCAM
3.0%(n=177)
7.3%(n=98)
4.8%(n=58)
13.4%(n=29)
users
27
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29

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USINGTHENATIONALHEALTHINTERVIEWSURVEYAND

Linkageof theNHISand MEPS datasetsyieldsatotalsample of2,411children. Thisis aninsufficient

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