1. The Relationship between Complementary and Alternative Medicine and Conventional Health Care Access, Expenditures and Experiences among US Children Presented by: Christina Bethell, PhD, MBA, MPH The Child and Adolescent Health Measurement Initiative Oregon Health & Science University Co-Authors: Paul Newacheck, Narangerel Gombojav, PhD, Scott Stumbo, MA, Cambria Wilhelm, MPH, John Neff, MD

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

3. Objectives 1.To calculate the prevalence of CAM use among children with chronic conditions and special health care needs 2.To assess the association between CAM use and conventional medical care (CM): utilization, access, parent's experience and CM expenditures 3.To evaluate the validity and sufficiency of available population based data to address priority integrative pediatrics health services research questions

4. Data: 1.2007 National Health Interview Survey (NHIS, n=9,417), 2.Linked file of the 2007 NHIS to the 2008 Medical Expenditure Panel Survey (MEPS) (n=2,411) 3.2009/10 National Survey of Children with Special Health Care Needs (NS-CSHCN; n=40,243). Primary Methods: Construct variables and estimate weighted prevalence Multivariate analyses were used to calculate adjusted odds ratios (AOR), controlling for children's chronic condition and special needs status and demographic characteristics. Data and Methods

5. Data Sets Sample Children in Data Files Sample Child File n=9,417 Family File n=29,915 Person File n=75,764 Sample Adult and Adult CAM File n=23,393 2007 NHIS Child CAM File n=9,417 2008 MEPS Full Year Consolidated Data File n=9,538 (children) 2007 NHIS 2008 MEPS (Panel 13) Linked File n=2,411 Office- Based Medical Provider Visits File Medical Conditions File Prescribed Medicines File 2007 NHIS 2008 MEPS At the family level Panel 13 child sample: n=5,769

6. CAM Modalities Asked in 2007 NHIS Child CAM Supplement 39 specific types of CAM modalities used in past 12 months (use of vitamins/minerals and herbal supplements in past 30 days among those who used in past 12 months) - DURING THE PAST 12 MONTHS, did [fill: S.C. name] see a provider or practitioner for any of the following therapies? Please say yes or no to each. Acupuncture? Two CAM Groupings 1.Products; Practices; Practitioners 2.Alternative Medical Systems; Biologically-Based Approaches; Manipulative and Body- Based Therapies; Mind-Body Therapies

7. Vitamins/minerals (VM) use 43.3% past 12 months 84.6% in past 30 days. CAM Use Definitions Previous Studies and Current Study *support group meeting and stress management class 4.2% to treat specific conditions 84.6% any of 59 conditions 59.3% any of 46 chronic conditions

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

9. Health Status: –CAM use is associated with the complexity and intensity of children’s health conditions. o CSHCN twice as likely to use CAM as non- CSHCN. o There is a linear relationship between the number of reported conditions and number of CAM modalities used. Results Who uses CAM?

10. Utilization of Conventional Medical Care: –Higher use of conventional medical care and higher expenditures was associated with CAM use –CAM use is more common among children who had difficulties accessing conventional medical care. –Children with complex condition whose parents are less satisfied with quality of conventional care (e.g. doctors’ communication) are more likely to use CAM. Results Who uses CAM?

11. Meta Data Issue #1 Results: Prevalence of Children Using CAM NHIS All Child Rate: The estimated prevalence of CAM* use among US children: 12.9% (9.4 million). 45.4% used 2+ types of CAM NHIS CSHCN Rate: 22.5% (40% CAM users are CSHCN using CAHMI constructed CSHCN variable); AOR: 2.25 MEPS CSHCN Rate: 23.6% (CSHCN Screener) NS-CSHCN Rate: 10.8% *includes vitamins/minerals used to treat specific conditions in past 30 days

12. Results: CAM Types Used Among CSHCN, 2007 NHIS and NHIS/MEPS RSE>30 p=0.13

13. CAM Use, by Condition Type Child Experiences, 2007 NHIS

14. CAM Use Among Children with Conditions Who Met the CSHCN Algorithm Criteria 7.6% AOR: 2.53* AOR: 4.13* Ref AOR: 2.26* AOR: 0.92 *statistically significant AORs adjusted for age, sex, race/ethnicity, income and region Ref AOR: 2.50* AOR: 4.65* Of 4.6% of children with back or neck pain 53.1% met the CSHCN algorithm criteria Of 7.2% of children with ADD/ADHD 84.8% met the CSHCN algorithm criteria

15. Variations In Use By Type of Health Conditions Child Experience

16. CAM use, by condition status CAM use, by number of conditions Relationship of CAM Use and Health Status Complexity, 2007 NHIS 7.6% NOTE: Percent shown in the boxes (white) are prevalence of conditions AOR: 2.52 (2.09-.3.03)

17. CAM Use Among CSHCN with Functional Difficulties 1 and Conditions 2, 2009/10 NS-CSHCN 1 from the list of 14 functional difficulties asked about 2 from the list of 20 conditions asked about *statistically significant MOTE: AORs are adjusted for age, sex, race/ethnicity, income, insurance type

18. CAM Use, by CSHCN Screener Qualifying Criteria, 2009/10 NS-CSHCN 3.9.3% 31.8% Ref: 1.00 AOR: 2.79* *statistically significant NOTE: AORs are adjusted for age, sex, race/ethnicity, income and insurance type

19. CAM Use and Average Number of Office-Based Visits (Adjusted and Unadjusted), NHIS/MEPS All childrenAmong CSHCN* Statistics Mean95% CIsp value 1 Mean95% CIsp value 1 Among children with office-based visits to physician and/or non-physician CAM users 6.04.8-7.2 <.0001 10.47.3-13.4.03 Non-CAM users 3.63.1-4.2 6.64.3-8.9 Among children who had office-based visits to physician CAM users 4.03.4-4.7.001 5.33.8-6.8.04 Non-CAM users 2.82.5-3.1 4.53.5-5.5 *CSHCN reported in MEPS 1 independent samples t test NOTE: Office-based non-physician visits include visits to chiropractors, nurse or nurse practitioner, optometrists, physician assistants, and physical or occupational therapist

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

21. Results: Quality of Care Did Not Meet MCHB CSHCN Core Outcomes, by CAM use, 2009/10 NS-CSHCN

22. Types of CAM Modalities Used and Health Care Access Problems (Unmet Needs or Delay), by Condition Type, 2007 NHIS Condition type Health care access problem Alternative Medical System/Energy healing 1 2.7% (n=231) Biologically-based therapies 2 5.8% (n=492) Manipulative and body-based therapies 3 3.7% (n=301) Mind-body therapies 4 4.7% (n=403) All children (n=9417) Of those with a problem (n=1572) 4.0% AOR: 1.48 10.1% AOR: 1.87 * 5.3% AOR: 1.52* 7.9% AOR: 1.80* Of those without a problem (n=7845) 2.5% Ref 5.0% Ref 3.4% Ref 4.0% Ref Among CSHCN (n=1981) Of those with a problem 5.4% AOR: 1.64 13.0% AOR: 1.45 7.7% AOR 1.78 * 13.5% AOR: 1.87* Of those without a problem 3.6% Ref 10.6% Ref 5.4% Ref 9.2% Ref Among children with at least 1 chronic condition (n=4902) Of those with a problem 4.5% AOR: 1.58* 12.6% AOR: 1.90* 6.7% AOR: 1.75* 10.3% AOR: 2.16* Of those without a problem 3.1% Ref 7.5% Ref 4.5% Ref 5.9% Ref Among, children with emotional, behavioral or mental condition (n=1307) Of those with a problem 6.2% AOR: 2.29* 14.6% AOR: 1.59* 9.1% AOR: 1.97* 17.1% AOR: 1.61* Of those without a problem 3.1% Ref 10.8% Ref 5.2% Ref 12.7% Ref Among children with pain-related condition (n=1084) Of those with a problem 4.8% AOR: 1.17 14.8% AOR: 1.69* 9.7% AOR: 0.89 13.6% AOR: 1.73* Of those without a problem 3.7% Ref: 10.2% Ref 10.4% Ref 8.9% Ref Among children with gastroenterology problem (n=2444) Of those with a problem 4.6% AOR: 1.47 14.6% AOR: 2.01* 7.3% AOR: 1.23 11.1% AOR: 1.81* Of those without a problem 3.1% Ref 7.9% Ref 5.9% Ref 6.9% Ref

23. CAM Use and Quality of Care, 2009/10 NS-CSHCN Ref AOR: 1.60*AOR: 1.52*

24. CAM Use and Health Care Expenditures (Adjusted), NHIS/MEPS Total health care expenditures CAM use status Children with expenditures Mean after adjusting covariates, among children with expenditures n%MeanCIp All children (n=2411) 201484.5%$1,5371,468-1,606NA CAM users (n=294) 26391.0%$2,3542,146-2,563 <.0001 Non-CAM users (n=2094) 173483.6%$1,382 1,319-1,445 Note: Expenditures were estimated by 2-part model adjusting age, sex, race/ethnicity, income, region and CSHCN status (NHIS) Out-of-pocked health care expenditures CAM use status Children with expenditures Mean after adjusting covariates, among children with expenditures n%MeanCIp All children (n=2411) 141164.8% $354332-377 NA CAM users (n=294) 20475.4% $476420-532 <.0001 Non-CAM users (n=2094) 119463.1% $329307-351

25. Sample size in linked NHIS/MEPS File –Prevents further analaysis of link between use of CAM in time 1 and conventional medical care in time 2 (suggestive findings) Methods for NHIS CAM Supplement Regarding “condition/reason for using CAM Key Limitations

26. Utilization of Emergency Room in Matched and Future Year of CAM Use, NHIS and NHIS/MEPS All children, 21.9% n=121

27. Hospitalization, by CAM Use and CSHCN Status, NHIS/MEPS MEPS – NHIS/MEPS Survey Item/Descri ption Data used to construct the inpatient utilization variable for newborns were edited to exclude stays where the newborn left the hospital on the same day as the mother. However, if the newborn was discharged at a later date than the mother was discharged, then the discharge was considered a separate stay for the newborn when constructing the utilization variable. All children 2.3% (n=57) Among CSHCN (MEPS) 4.0% (n=15) Among CAM users 2.4%* (n=12)2.5%* (n=3) Among non- CAM users 2.3% (n=45)3.9%* (n=12)

28. Results: CAM use and Most Common Conditions Reported in Sample Child Core and Child CAM Supplement Among children who experienced the condition ever 1 or in past 12 months (Sample Child Core), % children used CAM Conditions parents named as a reason to use CAM (Child CAM Supplement) Conditionsn% n% Congenital heart disease 1 845.8%Other - specify10410.0% Anxiety or stress (4-17 yrs)19936.6%Back or neck pain888.2% Back or neck pain12036.0%Head or chest cold728.1% Mental retardation 1 1634.4%Anxiety or stress555.7% Urinary tract infection3634.0%Musculoskeletal525.1% Depression (4-17 yrs)7433.0%Anemia353.4% Autism 1 2032.8%ADD/ADHD383.2% Fatigue or lack of energy10332.6%Asthma202.0% Other heart condition 1 2331.9%Sore throat other than strep.182.0% Insomnia (3-17 yrs)12831.8%Insomnia201.9% Severe acne6831.6%Depression211.7% Anemia3631.1%Allergies other than hay fever/resp., food/skin allergies, eczema 131.6%* * RSE>30 NOTE: Conditions with RSE>30 not listed

29. Additional Slides

30. Total Health Care Expenditures (Unadjusted), by Type of Services, NHIS/MEPS Types of services All childrenCAM usersNon-CAM users n%1%1 Mean 2 n%1%1 n%1%1 Total expenditures 2,01484.5% 1,88926391.0%3,101* 1,73483.6% 1,633 Total office-based visits 1,64770.6% 647 21673.4%1,429 1,41970.4% 506 Office-based visits to physicians 1,55165.6% 528 20368.1%1,118 1,33865.4% 421 Office-based visits to non- physicians 41421.3% 511 7628.2% 1,020 33520.3% 389 Total hospital outpatient visits 1496.8% 1,533 216.4% 2,8351276.9% 1,328 Total emergency room visits 32212.9% 932 4412.1% 879 27513.1% 941 Inpatient hospital stays552.2% 12,095 112.1% 17,348 442.2% 11,230 Prescription medication 1,12250.0% 439 15056.1% 1,063 96749.4% 315 1 % of children with expenditures 2 mean expenditures among children with expenditure *excluding extreme outlier

31. Identification of CSHCN in NHIS: NHIS Items Met CSHCN Screener Qualifying Criteria Table x

32. Identification of CSHCN in NHIS: Conditions A. Parents told by a HEALTH PROFESSIONAL that child had ever or in past 12 months n ADD/ADHD (2-17 years) 540 Mental retardation 54 Other developmental delay 274 Downs syndrome 12 Cerebral palsy (Q3 and 4) 11 Muscular dystrophy 3 Cystic fibrosis 1 Sickle cell anemia 17 Autism 58 Diabetes 17 Arthritis 10 Congenital heart disease 120 Other heart condition Asthma, with episode in past 12 months 485 Depression (4-17) 195 Learning disability (3-17) 557 Cancer 8 Neurological problem 108 Phobia or fears (4-17) 204 Gum disease 44 Lung or breathing problem (other than asthma) 318 Summary Measures of Health Conditions Comprehensive list (A, B, or C): Any listed conditions diagnosed by health professional, conditions reported by parents, VLBW Limited list (A or C): Any of listed health conditions diagnosed by health professional, VLBW B. Parents reported that child had any of listed conditions in past 12 months n Any seizure67 Respiratory allergy856 Eczema or skin allergy856 Food or digestive allergy378 Anemia121 Severe headaches/migraines (3-17)396 Frequent diarrhea or colitis155 Hay fever931 3 or more ear infection484 Recurring headache (non-migraine) (3-17)329 Stuttering or stammering (3-17)119 Other allergies451 Anxiety or stress (4-17)588 Sever acne246 Other chronic pain110 Fatigue or lack of energy293 C. Other condition** Child very low birth weight <1500g (VLBW)*, <2 years old 35 Table x

33. Adjusted Odds Ratios for Identification of CSHCN by Demographic Characteristics Characteristics 2007 NHIS (Algorithm) 2008 MEPS (Screener) 2007 NSCH (Screener) Age 0-5 years1.00 6-11 years1.51 (1.28 - 1.78)2.38 (1.95 - 2.91)2.19 (1.96 - 2.44) 12-17 years1.83 (1.56 - 2.14)2.54 (2.04 - 3.15)2.30 (2.06 - 2.56) Sex Male1.33 (1.17 - 1.51)1.71 (1.45 - 2.01)1.51 (1.40 - 1.64) Female1.00 Race/ethnicity White, non-Hispanic1.00 Hispanic 0.59 (0.50 - 0.70)0.47 (0.38 - 0.58)0.59 (0.50 - 0.69) Black, non-Hispanic 0.69 (0.57 - 0.85)0.86 (0.71 - 1.05)0.94 (0.84 - 1.06) Multi/other, non-Hispanic 0.71 (0.55 - 0.92)0.76 (0.58 - 1.01)0.76 (0.66 - 0.88) Family income 0-99% FPL 1.65 (1.33 - 2.05)1.08 (0.82 - 1.43)1.41 (1.24 - 1.60) 100-199% FPL 1.23 (1.03 - 1.47)1.04 (0.84 - 1.29)1.14 (1.02 - 1.28) 200-399% FPL 1.05 (0.90 - 1.22)0.93 (0.74 - 1.16)1.02 (0.92 - 1.13) 400% FPL or above1.00

34. Characteristics 2007 NHIS (n=9417) CSHCN 1 (algorithm) 2008 MEPS (n=9538) CSHCN 2 (Screener) NHIS/MEPS (n=2411) CSHCN 2 (Screener) Prevalence 22.1% (n=1981)18.4% (n=1541)21.4% (n=414) Age 0-5 years 25.5% (n=516)18.9% (n=314)20.3% (n=97) 6-11 years 33.5% (n=638)39.5% (n=631)33.7% (n=148) 12-17 years41.0% (n=827)41.6% (n=596)46.0% (n=169) Race White, non-Hips62.8% (n=1052)64.5% (n=657)66.6% (n=179) Hispanic16.7% (n=484)13.4% (n=360)13.4% (n=101) Black non-Hips13.8% (n=300)15.0% (n=394)12.7% (n=95) Insura nce Public insurance31.5% (n=638)31.9% (n=706)27.6% (n=168) Private insurance61.0% (n=1163)64.2% (n=769)67.1 %(n=224) Health/ Health Care Missed 11+ school days (5-17)10.1% (n=177)10.3% (n=114)12.4% (n=35) 2 or more ER visit14.7% (n=294)5.2% (n=86)4.0% (n=19) Children with expendituresNA96.2% (n=1467)97.3% (n=402) Characteristics of CSHCN Identified in the Study Data Files 1 Source of characteristics: NHIS, Sample child weights 2 Source of characteristics: MEPS, MEPS Person weights Table x

35. CSHCN Identified by the Algorithm in NHIS versus CSHCN Identified by the Screener in MEPS Of CSHCN identified by the Screener in MEPS (Panel 13), 59.9% 2 (n=237) have been identified as CSHCN by the algorithm in NHIS. (55.9% 1 of CSHCN identified by the algorithm met the Screener criteria) 38.8% 1 (n=440) of all child CAM users met criteria for having a special health care needs by the NHIS algorithm (42.0% 2 n=122 in the NHIS/MEPS). 30.4% 2 (n=76) of all child CAM users met criteria for having a special health care needs by the CSHCN Screener in NHIS/MEPS. Are they same children? Among CAM users, of children met CSHCN Screener criteria 81.2% 2 (n=59) have been identified as CSHCN by the algorithm (59.5% 2 of CSHCN identified by the algorithm met the Screener criteria) Note: 1 weighted by sample child weights 2 weighted by the linked file adjusted weights

36. Meta Data Issue #1 CAM Use and Conditions Conditions asked in Sample Child Core and Child CAM Supplement Validity, utility and repetitiveness of asking about conditions the child experiences and for which the child uses CAM.

37. Conditions Reported in Sample Child Core and Child CAM Supplement *from 59 conditions asked about

38. Among CAM users, % of Children Whose Parents Named Same Condition in Sample Child Core and Child CAM Supplement Conditions Used CAM Named the condition as a resaon to use CAM Parents named the same condition Among conditions in Sample Child, % named the condition in Child CAM Among conditions in Child CAM, % named the condition in Sample Child nnn% Autism n=58206628.6%*100.% Depression n=1957421 28.2%100% Food/digestive allergies n=3788711 12.4%*100.% Non-strep. sore throat n=280851418174.2%98.0% Insomnia n=38712820 14.9%89.9% ADD/ADHD n=540133383323.7%88.4% Head or chest cold n=4456708726511.3%88.3% Allergies other than hay fever/resp., food/skin allergies, eczema n=451 91121116.6%*86.9% Anxiety or stress n=538199554826.1%85.2% Anemia n=12136352569.0%66.8% Asthma n=48586201316.9%63.9% Back or neck pain n=311120885042.0% 52.7% *RSE>30 Table x

39. CAM Use for Children with Back or Neck Pain Prevalence of back or neck pain 3.4% n=311 Sample Child Core Child CAM Supplement Among children who experience back or neck pain, 36.0% of children used CAM (n=120)

40. Prevalence of depression 3.0% n=195 Child CAM Supplement 6.9% CAM Use for Children with Depression Among children who experience depression, 33.0% of children used CAM (n=74) Sample Child Core

41. 2007 NHIS and 2008 MEPS Linked File Linkage of NHIS and MEPS datasets result in 2,411 cases of data which is insufficient to validity explore the many condition specific patterns and associations critical to better understanding the need for and impact of integrative medicine in children.

42. Results Prevalence of CAM Use*, by CSHCN status CSHCN Prevalence: 2007 NHIS: 22.1% n=1981 2008 MEPS: 18.4% n=1541 NHIS/MEPS (CSHCN in NHIS): 23.0% n=518 NHIS/MEPS (CSHCN in MEPS): 21.4% n=414 2009/10 NS-CSHCN: 15.1% n=40242 *includes vitamins/minerals used for therapeutic purposes in past 30 days **CAM use is a singe item AOR adjusted by age, sex, race/ethnicity, income and region (2007 NHIS, Reference category: Non-CSHCN) n=1133 n=294

43. Children’s health status is more complex among CAM users compared to non-CAM users Children’s Health Status and Conditions Child Experiences 7.6% Table RF 6 p=<.0001

44. CAM users experience all types of conditions than those who did not use CAM. Type of Conditions Child Experiences, 2007 NHIS, by CAM Use Status 7.6% Table RF 6

45. Type of CAM Used, by Type of Condition Child Experiences, All Children, 2007 NHIS

46. 8 or More Medical Care Visits Among Children with Conditions, by CAM use 2007 NHIS AOR: 2.07*

47. For pop up only

48. Getting Needed Specialist Care for CSHCN, By CAM Use (NS-CSHCN) CAM use status NS-CSHCN received all needed SC (among who needed care) Access CSHCN 90.8% (n=18026) Among CAM users 86.5% AOR: 0.48 (0.37-0.63) Among non-CAM users 91.5% Ref: 1.00

49. Specialist Care, by CAM Use and CSHCN Status, NHIS 2007 NHIS Survey ItemCAU.240_00.000: DURING THE PAST 12 MONTHS, have you seen or talked to the following about [S.C. name]'s health? Inclusion/ exclusion of specialty A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/ gynecologist, psychiatrist or ophthalmologist?- asked separately) All children 13.2% (n=1183 Among CSHCN 30.6% (n=604) Among CAM users 23.3% AOR: 1.58 (1.25-1.98) 39.3% AOR: 1.50 (1.08-2.08) Among non- CAM users 11.4% Ref: 1.00 28.3% Ref: 1.00 *CAHPS section of MEPS NOTE: AOR: after adjusting age, sex, race/ethnicity, income, CSHCN status (for all children ONLY) and adult CAM use

50. Results: CAM use and Health Care Access Problems: Delay Getting Care 2009/10 NS_CSHCN

51. CAM Use and Quality of Care: Never/Sometimes Doctors Communicate Well, by Condition Status and Type, NHIS/MEPS AOR are adjusted by age, sex, race/ethnicity, income and region (CSHCN status for all children) *RSE>30 Condition typesAmong CAM users Among non-CAM users All children (n=2411) (controlling CSHCN in MEPS) 13.8% AOR: 1.71 (1.01-2.88) 9.9% Ref: 1.00 (controlling CSHCN in NHIS) AOR: 1.71 (1.00-2.94)Ref: 1.00 Among children with at least 1 chronic condition (n=1279) 14.8% AOR: 2.20 (1.23-3.95) 9.7% Ref: 1.00 Among, children with emotional, behavioral or mental conditions (n=351) 14.9%* AOR: 3.34 (1.02-10.90) 7.5% Ref: 1.00 Among children with pain-related condition (n=298) 9.1%* AOR: 1.64 (0.52-5.18) 10.1%* Ref: 1.00 Among children with gastroenterology problem (n=633) 19.2% AOR: 3.36 (1.41-8.01) 9.1% Ref: 1.00

52. AC27: Thinking about the types of medical, traditional and alternative treatments that (READ NAME(S) BELOW) are happy with, how often does {a medical person at} (PROVIDER) show respect for these treatments? Never/sometimes show respect Quality of Conventional Care and CAM use Status, by Condition Type Child Experiences n=152

53. AC28: If there were a choice between treatments, how often would {a medical person at} (PROVIDER) ask (READ NAME(S) BELOW) to help make the decision? Never/sometimes ask to help make the decision Quality of Conventional Care and CAM use Status, by Condition Type Child Experiences n=265

54. CAM use and Total and Out-Of-Pocket Health Care Expenditures (Adjusted), NHIS/MEPS Total health care expenditures CAM use status Children with expense Mean after adjusting covariates Median after adjusting covariates n%MeanCIpMeanCIp All children (n=2411) 201484.5%$1,462 (1,401-1,522)NA $999 CAM users (n=294) 26391.0%$2,281(2,079-2,483) <.0001 Non-CAM users (n=2094) 173483.6%$1,319(1,265-1,374) Note: Expenditures were estimated by 2-part model adjusting age, sex, race/ethnicity, income, region and CSHCN status (NHIS) Out-of-pocked health care expenditures CAM use status Children with expense Mean after adjusting covariates Median after adjusting covariates n%MeanCIpMeanCIp All children (n=2411)141164.8% $305 (284-326) $152 CAM users (n=294)20475.4% $426(367-486) <.0001 Non-CAM users (n=2094)119463.1% $285(264-306)

55. Number of CAM Modalities Used Among CSHCN CAM Users, 2007 NHIS and NHIS/MEPS Table x RSE>30

56. Prevalence of CAM Use By Unmet Needs for Conventional Medical Care Unmet needs for 5 services due to cost Ref *statistically significant