1. Methods for Evaluating Within-State Variations Using the National Survey of Children with Special Health Care Needs Virginia Sharp Center for Children with Special Needs

2. Overview >Why bother? >What sub-state geographic identifiers are available in national surveys? >What alternatives are available? >Accessing the data >Example of Rural-Urban differences in access to care in Washington state

3. Center for Children with Special Needs Why bother? >Statewide summary measures do not accurately reflect conditions in any particular segment of the state and may mask significant local issues >Health services are delivered locally >Limited health service dollars require targeting programs to meet specific needs >Local health jurisdictions need to be able to “see themselves” in the data.

4. Center for Children with Special Needs Geographic Identifiers in SLAITS >State >MSA status –MSAs define metropolitan areas as a core area with 50,000 or more inhabitants, such as a central city, along with the counties economically and socially connected to it –MSAs are not static; both their definition and application change over time

5. Center for Children with Special Needs Why not just use MSA Status? >Not available for all states –Required edits to protect confidentiality result in MSA status being suppressed whenever the total Census 2000 population of either the combined MSA counties or the combined non-MSA counties is less than 500,000 persons. –16 states affected in NS-CSHCN Why not just use MSA Status?

6. Center for Children with Special Needs Non-MSA population too small MSA population too small BOTH non-MSA & MSA populations too small Suppressed MSA status in NS-CSHCN Hawaii Alaska

7. Center for Children with Special Needs Why not just use MSA Status? >Not available for all states >Too little variation within many states –In Washington state, 85% of Census 2000 population in MSAs (12 counties) –2003 MSA definition adds 6 more counties, increasing to 89% of WA population in MSAs Why not just use MSA Status?

8. Center for Children with Special Needs MSAs in Washington State, 1999

9. Center for Children with Special Needs Why not just use MSA Status? >Not available for all states >Too little variation within many states >Differences in county size obscure differences across states –Yakima county, an MSA, is 4296 square miles –State of Delaware is 2489 square miles >Differences in county size obscure differences within states –Average population density in Yakima county was 51.8 persons per square mile Why not just use MSA Status?

10. Center for Children with Special Needs Rural Urban Commuting Area Codes >Census-tract based classification scheme >Uses standard Bureau of the Census urban area and place definitions in combination with commuting information >Characterizes each census tract based on population density, urbanization & daily commuting >Identifies urban core areas and adjacent territory that is economically integrated with those cores

11. Center for Children with Special Needs Rural Urban Commuting Area Codes >First developed from 1990 census data Released for both census tracts & zip code delivery areas >Revised for 2000 decennial census Census tract versions released March ‘05 Zip code versions coming soon >Developed by UW Rural Health Research Center with funding from US Dept. of Agriculture, Economic Research Service

12. Center for Children with Special Needs Why RUCAs? >Flexibility –10 primary codes –30 secondary codes –Allows for selective combination of codes to meet varying definitional needs >Based on smaller geographic areas –Census tracts/zip areas vs. counties >Consistent with OMB concepts of metropolitan and micropolitan areas

13. Center for Children with Special Needs Zip Code RUCAs, Washington 2000 Urban Core Suburban Large Town Small Town/Rural

14. Center for Children with Special Needs Accessing RUCAs for NS-CSHCN >Obtain zip code RUCAs for area of interest –http://www.ers.usda.gov/Data/RuralUrbanCo mmutingAreaCodes/ >Submit proposal to NCHS Research Data Center –http://www.cdc.gov/nchs/r&d/rdc.htm >Jump through the RDC’s hoops

15. Center for Children with Special Needs RDC Decisions >What specific survey files do you want to merge RUCA codes into? –$500 charge per file prepared by RDC >On-site or Remote Access? –On-site: SAS, SUDAAN, STATA, Fortran $200/day Normal business hours Output reviewed for disclosure issues

16. Center for Children with Special Needs RDC Decisions –Remote Access: SAS programs only –(certain procedures/functions not allowed) Submit programs via e-mail; results returned next day $500/month for any one data set

17. Center for Children with Special Needs RDC Issues >RDC is not “customer friendly” >Processes not always clear >If on-site, must allow sufficient time for RDC staff to review all output at end of day >RDC staff do not provide consultation on surveys themselves or statistical analysis >Must advocate for needs

18. Center for Children with Special Needs Examples from Washington State Sample Size 514 112 73 47

19. Center for Children with Special Needs Needed Routine Preventive Care Statewide mean = 74.6%

20. Center for Children with Special Needs Needed Specialized Therapies Statewide mean = 26.5%

21. Center for Children with Special Needs Received All Needed Dental Care Statewide mean = 89.5%

22. Center for Children with Special Needs Received All Needed Mental Health Care Statewide mean = 79.9%

23. Center for Children with Special Needs Child has 2+ Unmet Health Needs Statewide mean = 5.8%

24. Center for Children with Special Needs Family has Unmet Service Needs Statewide mean = 8.4%

25. Center for Children with Special Needs Topics for Further Study >Is statistical significance at the 95% confidence level necessary for within-state disparities to be important to public health agencies? >How can these findings be used by MCH agencies to reduce geographic disparities? >To what extent are within-state disparities in access to care for CSHCN a function of agency structure? Is there a “most efficient” structure for equitable access to CSHCN-related services? >Would alternate rural-urban definitions yield the same or similar results?

26. Center for Children with Special Needs Conclusions >Within-state variation in access to care based on rural-urban setting for CSHCN can be significant >Working through the Research Data Center at NCHS, analyses of within-state variation can be conducted on the NS-CSHCN & NS-CH >These data cannot be used to identify issues in specific places within a state >States interested in improving their ability to understand within-state patterns should invest in additional sample size in future surveys

27. Contact Information: Ginny.Sharp@seattlechildrens.org (206) 987-5311 Funding from the Washington State Department of Health, CSHCN Program and an MCHB CSHCN Financing Grant supported this research.