Taking stock of the CSHCN screener: a review of common questions and current reflections.

Since 2000, the Children with Special Health Care Needs (CSHCN) Screener (CS) has been widely used nationally, by states, and locally as a standardized and brief survey-based method to identify populations of children who experience chronic physical, mental, behavioral, or other conditions and who also require types and amounts of health and related services beyond those routinely used by children. Common questions about the CS include those related to its development and uses; its conceptual framework and potential for under- or overidentification; its ability to stratify CSHCN by complexity of service needs and daily life impacts; and its potential application in clinical settings and comparisons with other identification approaches. This review recaps the development, design, and findings from the use of the CS and synthesizes findings from studies conducted over the past 13 years as well as updated findings on the CS to briefly address the 12 most common questions asked about this tool through technical assistance provided regarding the CS since 2001. Across a range of analyses, the CS consistently identifies a subset of children with chronic conditions who need or use more than a routine type or amount of medical- and health-related services and who share common needs for health care, including care coordination, access to specialized and community-based services, and enhanced family engagement. Scoring algorithms exist to stratify CSHCN by complexity of needs and higher costs of care. Combining CS data with clinical diagnostic code algorithms may enhance capacity to further identify meaningful subgroups. Clinical application is most suited for identifying and characterizing populations of patients and assessing quality and system improvement impacts for children with a broad range of chronic conditions. Other clinical applications require further implementation research. Use of the CS in clinical settings is limited because integration of standardized patient-reported health information is not yet common practice in most settings or in electronic health records. The CS continues to demonstrate validity as a non-condition-specific, population-based tool that addresses many of the limits of condition or diagnosis checklists, including the relatively low prevalence of many individual conditions and substantial within-diagnosis variations and across-diagnoses similarities in health service needs, functioning, and quality of care.

Assessing systems quality in a changing health care environment: the 2009-10 national survey of children with special health care needs.

To provide a national, population-based assessment of the quality of the health care system for children and youth with special health care needs using a framework of six health care system quality indicators. 49,242 interviews with parents of children with special health care needs from the 2009-10 National Survey of Children with Special Health Care Needs (NS-CSHCN) were examined to determine the extent to which CSHCN had access to six quality indicators of a well-functioning system of services. Criteria for determining access to each indicator were established and applied to the survey data to estimate the proportion of CSHCN meeting each quality indicator by socio-demographic status and functional limitations. 17.6% of CSHCN received care consistent with all six quality indicators. Results for each component of the system quality framework ranged from a high of 70.3% of parents reporting that they shared decision-making with healthcare providers to a low of 40% of parents reporting receipt of services needed for transition to adult health care. Attainment rates were lower for CSHCN of minority racial and ethnic groups, those residing in households where English was not the primary language, those in lower income households, and those most impacted by their health condition. Only a small proportion of CSHCN receive all identified attributes of a high-quality system of services. Moreover, significant disparities exist whereby those most impacted by their conditions and those in traditionally disadvantaged groups are served least well by the current system. A small proportion of CSHCN appear to remain essentially outside of the system, having met few if any of the elements studied.

Changing trends of childhood disability, 2001-2011.

BACKGROUND: Over the past half century the prevalence of childhood disability increased dramatically, coupled with notable increases in the prevalence of mental health and neurodevelopmental conditions. This study provides a detailed assessment of recent trends in childhood disability in relation to health conditions and sociodemographic factors. METHODS: Secondary data analysis of National Health Interview Survey (NHIS) datasets 2001-2002, 2004-2005, 2007-2008, and 2010-2011 (N = 198888) was conducted to calculate the prevalence, rate of change, severity, and sociodemographic disparities of parent-reported childhood disability. RESULTS: The prevalence of childhood disability has continued to increase, growing by 15.6% between 2001-2002 and 2010-2011. Nearly 6 million children were considered disabled in 2010-2011. Children living in poverty experienced the highest rates of disability, 102.6 cases per 1000 population in 2010-2011, but unexpectedly, children living in households with incomes ≥ 400% above the federal poverty level experienced the largest increase (28.4%) over this 10-year period. The percentage of disability cases related to any physical health condition declined 11.8% during the decade, whereas cases related to any neurodevelopmental or mental health condition increased by 20.9%. CONCLUSIONS: Over the past decade, parent-reported childhood disability steadily increased. As childhood disability due to physical conditions declined, there was a large increase in disabilities due to neurodevelopmental or mental health problems. For the first time since the NHIS began tracking childhood disability in 1957, the rise in reported prevalence is disproportionately occurring among socially advantaged families. This unexpected finding highlights the need to better understand the social, medical, and environmental factors influencing parent reports of childhood disability.

Optimizing health and health care systems for children with special health care needs using the life course perspective.

To date, life course research in maternal and child health has largely focused on elucidating fetal and early life influences on adult health and less on promoting the health of children with special health care needs (CSHCN). Consideration of life course theory (LCT) for CSHCN is especially important given their increasing prevalence and comorbidity, their disproportionate vulnerability to weaknesses or instability in the health care system, and the growing evidence linking child and adult health and quality of life. In this commentary we seek to advance the consideration of LCT for CSHCN. We (1) briefly summarize key issues and the importance of a life course approach for CSHCN; (2) present illustrative findings from population-based cross-sectional data that serve to generate hypotheses that can be more rigorously examined when population-based longitudinal data become available; and (3) discuss the application of life course principles as a driving force in the continued implementation and improvement of integrated systems of care for CSHCN.

Medical home for adolescents: low attainment rates for those with mental health problems and other vulnerable groups.

BACKGROUND: The importance of the medical home for children has been demonstrated but has not been examined comprehensively for adolescents. Adolescence is a unique period of physical, cognitive, and psychosocial changes when many mental disorders first emerge; thus, receiving care within a medical home could improve well-being. This study examines rates of medical home attainment and its components for adolescents and subgroups, including those with mental health conditions. METHODS: Utilizing the 2007 National Survey of Children's Health, we determined the following for adolescents aged 10 to 17 years (n = 45 897): 1) rates of medical home attainment and its 5 components (usual source of care, having a personal doctor, and receiving needed referrals, effective care coordination, and family-centered care); and 2) subgroup differences; gender, race/ethnicity, income, insurance, region, language spoken at home, respondent education, and the presence of mental health conditions. RESULTS: Fifty-four percent of adolescents had a past-year medical home. Rates were lower for minority youth compared to whites; lower-income and uninsured youth; those in households that are non-English speaking in which the respondent did not have some college; and those with mental health as opposed to physical health conditions (all P < .01). Patterns of disparities in the medical home components were similar, and rates were lowest for effective care coordination and family-centered care components. CONCLUSIONS: Nearly half of adolescents lacked a medical home in the past year. Even lower rates for subgroups highlight the need to increase access to comprehensive quality health care. Efforts to improve effective care coordination and family-centered care could result in higher quality of care for all children and adolescents, and specifically for disadvantaged adolescents and those with mental health conditions.

An examination of racial/ethnic disparities in children's oral health in the United States.

OBJECTIVE: To assess the extent factors other than race/ethnicity explain apparent racial/ethnic disparities in children's oral health and oral health care. METHODS: Data were from the 2007 National Survey of Children's Health, for children 2-17 years (n=82,020). Outcomes included parental reports of child's oral health status, receiving preventive dental care, and delayed dental care/unmet need. Model-based survey-data-analysis examined racial/ethnic disparities, controlling for child, family, and community/state (contextual) factors. RESULTS: Unadjusted results show large racial/ethnic oral health disparities. Compared with non-Hispanic White people, Hispanic and non-Hispanic-Black people were markedly more likely to be reported in only fair/poor oral health [odds ratios (ORs) (95% confidence intervals) 4.3 (4.0-4.6), 2.2 (2.0-2.4), respectively], lack preventive care [ORs 1.9 (1.8-2.0), 1.4 (1.3-1.5)], and experience delayed care/unmet need [ORs 1.5 (1.3-1.7), 1.4 (1.3-1.5)]. Adjusting for child, family, and community/state factors reduced racial/ethnic disparities. Adjusted ORs (AORs) for Hispanics and non-Hispanic Blacks attenuated for fair/poor oral health, to 1.6 (1.5-1.8) and 1.2 (1.1-1.4), respectively. Adjustment eliminated disparities for lacking preventive care [AORs 1.0 (0.9-1.1), 1.1 (1.1-1.2)] and in Hispanics for delayed care/unmet need (AOR 1.0). Among non-Hispanic Blacks, adjustment reversed the disparity for delayed care/unmet need [AOR 0.6 (0.6-0.7)]. CONCLUSIONS: Racial/ethnic disparities in children's oral health status and access were attributable largely to socioeconomic and health insurance factors. Efforts to decrease disparities may be more efficacious if targeted at social, economic, and other factors associated with minority racial/ethnic status and may have positive effects on all who share similar social, economic, and cultural characteristics.

Racial disparity trends in children's dental visits: US National Health Interview Survey, 1964-2010.

BACKGROUND AND OBJECTIVE: Research that has repeatedly documented marked racial/ethnic disparities in US children's receipt of dental care at single time points or brief periods has lacked a historical policy perspective, which provides insight into how these disparities have evolved over time. Our objective was to examine the im-pact of national health policies on African American and white children's receipt of dental care from 1964 to 2010. METHODS: We analyzed data on race and dental care utilization for children aged 2 to 17 years from the 1964, 1976, 1989, 1999, and 2010 National Health Interview Survey. Dependent variables were as follows: child's receipt of a dental visit in the previous 12 months and child's history of never having had a dental visit. Primary independent variable was race (African American/white). We calculated sample prevalences, and χ(2) tests compared African American/white prevalences by year. We age-standardized estimates to the 2000 US Census. RESULTS: The percentage of African American and white children in the United States without a dental visit in the previous 12 months declined significantly from 52.4% in 1964 to 21.7% in 2010, whereas the percentage of children who had never had a dental visit declined significantly (P < .01) from 33.6% to 10.6%. Pronounced African American/white disparities in children's dental utilization rates, whereas large and statistically significant in 1964, attenuated and became nonsignificant by 2010. CONCLUSIONS: We demonstrate a dramatic narrowing of African American/white disparities in 2 measures of children's receipt of dental services from 1964 to 2010. Yet, much more needs to be done before persistent racial disparities in children's oral health status are eliminated.

Interventions to improve screening and follow-up in primary care: a systematic review of the evidence.

BACKGROUND: The American Academy of Pediatrics and other organizations recommend several screening tests as part of preventive care. The proportion of children who are appropriately screened and who receive follow-up care is low. OBJECTIVE: To conduct a systematic review of the evidence for practice-based interventions to increase the proportion of patients receiving recommended screening and follow-up services in pediatric primary care. DATA SOURCE: Medline database of journal citations. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: We developed a strategy to search MEDLINE to identify relevant articles. We selected search terms to capture categories of conditions (eg, developmental disabilities, obesity), screening tests, specific interventions (eg, quality improvement initiatives, electronic records enhancements), and primary care. We searched references of selected articles and reviewed articles suggested by experts. We included all studies with a distinct, primary care-based intervention and post-intervention screening data, and studies that focused on children and young adults (≤21 years of age). We excluded studies of newborn screening. STUDY APPRAISAL AND SYNTHESIS METHODS: Abstracts were screened by 2 reviewers and articles with relevant abstracts received full text review and were evaluated for inclusion criteria. A structured tool was used to abstract data from selected articles. Because of heterogeneous interventions and outcomes, we did not attempt a meta-analysis. RESULTS: From 2547 returned titles and abstracts, 23 articles were reviewed. Nine were pre-post comparisons, 5 were randomized trials, 3 were postintervention comparisons with a control group, 3 were postintervention cross-sectional analyses only, and 3 reported time series data. Of 14 articles with preintervention or control group data and significance testing, 12 reported increases in the proportion of patients appropriately screened. Interventions were heterogeneous and often multifaceted, and several types of interventions, such as provider/staff training, electronic medical record templates/prompts, and learning collaboratives, appeared effective in improving screening quality. Few articles described interventions to track screening results or referral completion for those with abnormal tests. Data were often limited by single-site, nonrandomized design. CONCLUSIONS: Several feasible, practice- and provider-level interventions appear to increase the quality of screening in pediatric primary care. Evidence for interventions to improve follow-up of screening tests is scant. Future research should focus on which specific interventions are most effective, whether effects are sustained over time, and what interventions improve follow-up of abnormal screening tests.

The changing landscape of disability in childhood.

Americans' perceptions of childhood disability have changed dramatically over the past century, as have their ideas about health and illness, medical developments, threats to children's health and development, and expectations for child functioning. Neal Halfon, Amy Houtrow, Kandyce Larson, and Paul Newacheck examine how these changes have influenced the risk of poor health and disability and how recent policies to address the needs of children with disabilities have evolved. The authors examine the prevalence in the United States of childhood disability and of the conditions responsible for impairment, as well as trends in the prevalence of chronic conditions associated with disability. They find that childhood disability is increasing and that emotional, behavioral, and neurological disabilities are now more prevalent than physical impairments. They stress the importance of, and lack of progress in, improving socioeconomic disparities in disability prevalence, as well as the need for better measures and greater harmonization of data and data sources across different child-serving agencies and levels of government. They call on policy makers to strengthen existing data systems to advance understanding of the causes of childhood disabilities and guide the formulation of more strategic, responsive, and effective policies, programs, and interventions. The authors offer a new and forward-looking definition of childhood disability that reflects emerging and developmentally responsive notions of childhood health and disability. They highlight the relationship between health, functioning, and the environment; the gap in function between a child's abilities and the norm; and how that gap limits the child's ability to engage successfully with his or her world. Their definition also recognizes the dynamic nature of disability and how the experience of disability can be modified by the child's environment.

A national and state profile of leading health problems and health care quality for US children: key insurance disparities and across-state variations.

BACKGROUND: Parent/consumer-reported data is valuable and necessary for population-based assessment of many key child health and health care quality measures relevant to both the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 and the Patient Protection and Affordable Care Act of 2010 (ACA). OBJECTIVES: The aim of this study was to evaluate national and state prevalence of health problems and special health care needs in US children; to estimate health care quality related to adequacy and consistency of insurance coverage, access to specialist, mental health and preventive medical and dental care, developmental screening, and whether children meet criteria for having a medical home, including care coordination and family centeredness; and to assess differences in health and health care quality for children by insurance type, special health care needs status, race/ethnicity, and/or state of residence. METHODS: National and state level estimates were derived from the 2007 National Survey of Children's Health (N = 91,642; children aged 0-17 years). Variations between children with public versus private sector health insurance, special health care needs, specific conditions, race/ethnicity, and across states were evaluated using multivariate logistic regression and/or standardized statistical tests. RESULTS: An estimated 43% of US children (32 million) currently have at least 1 of 20 chronic health conditions assessed, increasing to 54.1% when overweight, obesity, or being at risk for developmental delays are included; 19.2% (14.2 million) have conditions resulting in a special health care need, a 1.6 point increase since 2003. Compared with privately insured children, the prevalence, complexity, and severity of health problems were systematically greater for the 29.1% of all children who are publicly insured children after adjusting for variations in demographic and socioeconomic factors. Forty-five percent of all children in the United States scored positively on a minimal quality composite measure: 1) adequate insurance, 2) preventive care visit, and 3) medical home. A 22.2 point difference existed across states and there were wide variations by health condition (autism, 22.8, to asthma, 39.4). After adjustment for demographic and health status differences, quality of care varied between children with public versus private health insurance on all but the following 3 measures: not receiving needed mental health services, care coordination, and performance on the minimal quality composite. A 4.60 fold (gaps in insurance) to 1.27 fold (preventive dental and medical care visits) difference in quality scores was observed across states. Notable disparities were observed among publicly insured children according to race/ethnicity and across all children by special needs status and household income. CONCLUSIONS: Findings emphasize the importance of health care insurance duration and adequacy, health care access, chronic condition management, and other quality of care goals reflected in the 2009 CHIPRA legislation and the ACA. Despite disparities, similarities for public and privately insured children speak to the pervasive nature of availability, coverage, and access issues for mental health services in the United States, as well as the system-wide problem of care coordination and accessing specialist care for all children. Variations across states in key areas amenable to state policy and program management support cross-state learning and improvement efforts.

The medical home: health care access and impact for children and youth in the United States.

OBJECTIVE: The medical home concept encompasses the elements of pediatric care considered essential for all children. We describe here the characteristics of children with medical homes and the relationship between presence of a medical home and selected health care outcomes by using new data from the 2007 National Survey of Children's Health (NSCH). METHODS: We used a medical home measure comprising 5 components: having a usual source of care; having a personal physician or nurse; receiving all needed referrals for specialty care; receiving help as needed in coordinating health and health-related care; and receiving family-centered care. A total of 83 448 children aged 1 to 17 years had valid data for all applicable medical home components. The NSCH is a random-digit-dial population-based telephone survey. RESULTS: In 2007, 56.9% of US children aged 1 to 17 years received care in medical homes. Younger children were more likely to have a medical home than their older counterparts. Substantial racial/ethnic, socioeconomic, and health-related disparities were present. Children who received care in medical homes were less likely to have unmet medical and dental needs and were more likely to have annual preventive medical visits. CONCLUSIONS: Approximately half of the children in the United States have access to all components of a pediatric medical home. Because the medical home is increasingly promoted as the standard for provision of high-quality comprehensive health care, these findings reinforce the need to continue and expand federal, state, and community efforts to ensure that all children have access to this model of care.

Evidence for family-centered care for children with special health care needs: a systematic review.

OBJECTIVE: Family-centered care (FCC) has received widespread endorsement for use in care in the United States. In this study, we conducted a systematic review of evidence for FCC focusing specifically on family-provider partnership as the activity that constitutes FCC. METHODS: We found and reviewed articles from the medical, nursing, psychology, and sociology literature spanning 1986 to 2010. We also reviewed articles obtained through related references and through recommendations from key informants. Four sets of terms were used to search, including FCC, child/adolescent, children with special health care needs (CSHCN, defined broadly or by condition), and a relevant outcome. RESULTS: Twenty-four studies met the review criteria. Eight were cross-sectional studies from the National Survey of Children With Special Health Care Needs, and 7 were reports of randomized, controlled trials. Of the 24 articles reviewed, 13 examined populations of CSHCN or similar populations, 6 examined children with asthma, and the remaining studied children with other specific conditions. We found positive associations of FCC with improvements in efficient use of services, health status, satisfaction, access to care, communication, systems of care, family functioning, and family impact/cost. There was little available evidence, however, for some outcomes, including cost and transition. CONCLUSIONS: The available evidence suggests that FCC is associated with improved outcomes for CSHCN. With positive findings for most of the studies reviewed here and the compelling arguments for FCC, we recommend the use of this approach by individuals and organizations.

Assessing family-provider partnerships and satisfaction with care among US children with special health care needs.

OBJECTIVES: Family-provider partnerships and satisfaction with services together are one of the Health Resources and Services Administration's (HRSA) Maternal and Child Health Bureau's (MCHB) 6 core outcomes for children with special health care needs (CSHCN) and are tracked using the 2005-2006 National Survey of Children with Special Health Care Needs. Our objectives were to examine demographic, health, and other correlates/associations, with the perception of family-provider partnership and satisfaction with care; determine the associations between these perceptions and other child/family outcomes; and evaluate differences in the perception of partnership and satisfaction between the families of CSHCN and other children. METHODS: We analyzed data for 40,723 CSHCN from the 2005-2006 National Survey of CSHCN and assessed the prevalence of family-provider partnerships and satisfaction with care and their association with other family-child outcomes. The partnership/satisfaction core outcome results were compared with a referent group of children without special needs included in the 2005-2006 survey. RESULTS: The proportion of CSHCN attaining the core outcome was 57.4% and was lower for households with no health insurance, minority ethnic status, non-English speakers, nontraditional family structure, lower income, and lower functioning CSHCN. Lower rates of satisfaction and partnership were associated with poorer child and family outcomes. Disparities in attainment rates were noted for CSHCN versus other children. CONCLUSIONS: Although parent perceptions of family-provider partnership were relatively high, satisfaction with care contributed to an overall lower attainment rate for the partnership/satisfaction core outcome. Providers, families, government, and advocates need to work together to increase attainment of family-provider partnerships and satisfactory care experiences.

Assessing and ensuring a comprehensive system of services for children with special health care needs: a public health approach.

The US Department of Health and Human Services called for comprehensive systems of services for children with special health care needs in its Healthy People 2000 and 2010 health care objectives for the nation. We report on the proportion of children with special health care needs receiving care in high-quality systems of services measured by attainment of 6 essential system elements, or quality indicators, generated from a survey of 40,723 families of children with special health care needs in 2005 to 2006. Only 17.7% of children with special health care needs received services in a high-quality service system that met all 6 quality indicators in 2005-2006. Therefore, much more work lies ahead to meet the national Healthy People objective for these children.

Underinsurance among children in the United States.

BACKGROUND: Recent interest in policy regarding children's health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children's needs. METHODS: We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children's Health (sample size, 91,642 children) regarding parents' or guardians' judgments of whether their children's insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home. RESULTS: We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage--14.1 million children--were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality. CONCLUSIONS: The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)

The impact of parental job loss on children's health insurance coverage.

Children with private health insurance are more than six and a half times as likely to lose coverage in the three months after one or both of their parents loses a job, compared to children whose parents remain employed. In the current economic environment, this finding is especially troubling. We estimate that for every 1,000 jobs lost, 311 privately insured children lose coverage and more than 45 percent of the poorest and most vulnerable of privately insured children became uninsured. Much more effort is needed to quickly enroll children in public health insurance programs when their parents suffer a job loss.

Assessing a multilevel model of young children's oral health with national survey data.

OBJECTIVES: To empirically test a multilevel conceptual model of children's oral health incorporating 22 domains of children's oral health across four levels: child, family, neighborhood and state. DATA SOURCE: The 2003 National Survey of Children's Health, a module of the State and Local Area Integrated Telephone Survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics, is a nationally representative telephone survey of caregivers of children. STUDY DESIGN: We examined child-, family-, neighborhood-, and state-level factors influencing parent's report of children's oral health using a multilevel logistic regression model, estimated for 26 736 children ages 1-5 years. PRINCIPAL FINDINGS: Factors operating at all four levels were associated with the likelihood that parents rated their children's oral health as fair or poor, although most significant correlates are represented at the child or family level. Of 22 domains identified in our conceptual model, 15 domains contained factors significantly associated with young children's oral health. At the state level, access to fluoridated water was significantly associated with favorable oral health for children. CONCLUSIONS: Our results suggest that efforts to understand or improve children's oral health should consider a multilevel approach that goes beyond solely child-level factors.

State variation in underinsurance among children with special health care needs in the United States.

OBJECTIVE: National attention has focused on providing health insurance coverage for children. Less awareness has been given to underinsurance, particularly for children with special health care needs (CSHCN). Defined as having inadequate benefits, underinsurance may be a particular problem for CSHCN because of their greater needs for medical care. METHODS: We used the 2005-2006 National Survey of Children With Special Health Care Needs, a nationally representative study of >40,000 CSHCN, to address state variations in underinsurance. CSHCN with health insurance were considered underinsured when a parent reported that the child's insurance did not usually or always cover needed services and providers or reasonably cover costs. We calculated the unadjusted prevalence of underinsurance for each state. Using logistic regression, we estimated state-specific odds and prevalence for underinsurance after adjusting for poverty level, race/ethnicity, gender, family structure, language use, insurance type, and severity of child's health condition. We also conducted multilevel analyses incorporating state-level contextual data on Medicaid and the State Children's Health Insurance Program. RESULTS: Bivariate and multivariate analyses indicated that CSHCN's state of residence had a strong association with insurance adequacy. State-level unadjusted underinsurance rates ranged from 24% (Hawaii) to 38% (Illinois). After multivariate adjustments, the range was largely unchanged: 23% (Hawaii) to 38% (New Jersey). Multilevel analyses indicated that Medicaid income eligibility levels were inversely associated with the odds of being underinsured. CONCLUSIONS: The individual-level and macro-level factors examined only partly explain state variations in underinsurance. Furthermore, the macro-level factors explained only a small portion of the variance; however, other macro-level factors may be relevant for the observed patterns.

Prevalence of obesity among children with chronic conditions.

New evidence suggests that children with chronic conditions may be predisposed to overweight and obesity. This study provides prevalence estimate of obesity for children and adolescents with select chronic conditions. We analyzed reported height and weight and the corresponding BMI from 46,707 subjects aged 10-17 years collected by the National Survey of Children's Health (NSCH-2003). Our main outcome measure was the prevalence of obesity (defined as >/=95th percentile of the sex-specific BMI for age growth charts), adjusted for underlying demographic and socioeconomic factors. We found that the prevalence of obesity among children 10-17 years of age without a chronic condition was 12.2% (95% confidence interval (CI) 11.5-13.0); the prevalence of obesity for children with asthma was 19.7% (19.5-19.9); with a hearing/vision condition was 18.4% (18.2-18.5); with learning disability was 19.3% (19.2-19.4); with autism was 23.4% (23.2-23.6); and with attention-deficit/hyperactivity disorder was 18.9% (18.7-19.0). Our findings suggest that children 10-17 years of age with select chronic conditions were at increased risk for obesity compared to their counterparts without a chronic condition.