Identifying and Classifying Children With Chronic Conditions Using Administrative Data

Objective.—To identify and categorize children with chronic health conditions using administrative data. Methods.—The Clinical Risk Groups (CRGs) system is used to classify children, aged 0–18 years, in a mid-sized health plan into mutually exclusive categories and severity groups. Enrollees are categorized into 9 health status groups— healthy, significant acute, and 7 chronic conditions—and are then stratified by severity. Utilization is examined by category and severity level based on eligibility and claims files for calendar year 1999. Only children enrolled for at least 6 months (newborns at least 3 months) are included. Results.—This analysis of 34 544 children classifies 85.2% as healthy, including 19.6% with no claims; 5.2% with a significant acute illness; 4.6% with a minor chronic condition; and 4.9% with a moderate to catastrophic chronic condition. The average number of unique medical care encounters per child increases by chronic condition category and by severity level. Compared to national prevalence norms for selected conditions, CRGs do well in identifying patients who have conditions that require interaction with the health care system. Conclusions.—CRGs are a useful tool for identifying, classifying, and stratifying children with chronic health conditions. Enrollees can be grouped into categories for patient tracking, case management, and utilization.