Improvement in Asthma Care After Enrollment in SCHIP
Peter G. Szilagyi MD, MPH1,2 Andrew W. Dick PhD2
Jonathan D. Klein MD, MPH1,2 Laura P Shone, MSW, DrPH1
Alina Bajorska MS2 Jack Zwanziger PhD4
Lorrie Yoos, PhD, PNP1,31Dept. of Pediatrics2Dept. Of Community & Preventive Medicine University of Rochester3School of Nursing
4School of Public Health, Univ. of Chicago
Background - SCHIP State Children’s Health Insurance Program
$40 billion, block grants to states (10 years) Low-income children not eligible for Medicaid
SCHIP in New York State (2002) Acts like a separate program (not Medicaid) Administered through MCOs Enrollment = 600,000 (18% of US)
Important to measure how well SCHIP works For children in general and those with chronic conditions
Children with Asthma Most common chronic physical child condition
5-10% of children
More prevalent and problematic among the poor
High utilization and costs (visits, medications)
NHLBI guidelines for care exist Preventive visits and meds
Prior studies: Problems with access if no coverage
Study Objectives
Describe characteristics of SCHIP enrollees with asthma
Prevalence in SCHIP Severity of asthma
Measure effect of SCHIP on children with asthma Utilization of services Quality of care Asthma outcomes
Study Design
Pre-Post telephone interviews of parents of SCHIP enrollees
Interview Measurement Period
T1 Soon after enrollment Year before SCHIP
T2 12 months later 1st year during SCHIP
Comparison group who enrolled 1 year later To test for secular trends (few trends found)
Subjects:Main Study- All Children
Stratified sample of children by:– Region: NYC, NYC environs, upstate urban, rural– Age: 0-5 yr, 6-11 yr, 12-18 yr– Race/ethnicity: White NH, Black NH, Hispanic
2,644 first-time SCHIP enrollees– Enrolled between Nov 2000 and March 2001– 2,290 (87%) completed interviews 1 year later (2001-2002)
400 Comparison group subjects– Random sample
Asthma Screener Methods*
1. During past year, did MD say child had asthma
or
2. Did child have any of the following apart from a cold?
Wheezing or whistling in chest Chest sounding wheezy during or after exercise Waking from sleep because of cough or wheeze Wheezing severe enough to limit speech
*Questions adapted from NHLBI guidelines – Child had asthma if YES to either #1 or #2
Asthma Screener: Prevalence
Time Period # Children Asthma during:
T1 334 (13%)Year before SCHIP
T2 364 (14%)Year during SCHIP
T1 and T2 213 (8% of T1) Both years
T1 or T2 472 Either year
Asthma Screener: Prevalence
Time Period # Children Asthma during:
T1 334 (13%) Year before SCHIP
T2 364 (14%) Year during SCHIP
T1 and T2 213 (8% of T1) Both years
T1 or T2 472 Either year
Children “grow out” and “grow into” asthma between T1 & T2
Limitations exist in any choice of sample to study
Analyses performed multiple ways same results
Asthma Screener: Prevalence
Time Period # Children Asthma during:
T1 334 (13%) Year before SCHIP
T2 364 (14%) Year during SCHIP
T1 and T2 213 (8% of T1) Both years
T1 or T2 472 Either year
Children “grow out” and “grow into” asthma between T1 & T2
Limitations exist in any choice of sample to study
Analyses performed multiple ways same results
Questions to IdentifyAsthma Severity*
- Frequency of asthma symptoms
- Limitations of activities
- Nighttime awakening due to asthma
“Mild” “Moderate to severe”
*Questions adapted from NHLBI guidelines
Questions to IdentifyAsthma Severity – at T1
- Frequency of asthma symptoms
- Limitations of activities
- Nighttime awakening due to asthma
“Mild ” “Moderate to Severe”
334
202 (60%) 132 (40%)
Measures and Analyses
Measures Access: Usual Source of Care (USC), Unmet needs Use of care: Preventive, acute, specialty Quality measures: % of visits to USC, parent ratings of
quality Asthma-specific: Use of care, severity, quality
Analyses Bivariate and multivariate
Comparing measures: “pre-SCHIP” vs “during SCHIP” Secular trends: Study group vs Comparison group (few found) Results weighted using STATA to account for complex sampling
design
Results: Demographicsof Children with Asthma
(N=472)
Region: 64% New York city, 18% around NYC
Age: balanced across ages from 0-17 years
Gender: half male
Race and ethnicity: 23% white, 40% black, 34% Hispanic
Income: 80% below 160% of FPL
Parent Employment: 83% had > 1 parent working
Prior Insurance: 71% uninsured >12m before SCHIP
Access: USCBefore SCHIP and 1 Year After Enrollment
95
99
60
70
80
90
100
BeforeAfter
Accessibility Measures(Children with Asthma) Travel > ½ hour to MD
29% to 6% ( p<.001)
Difficulty getting appt. 12% to 4% ( p<.01)
Wait > 15 minutes at visit No improvement
Had Usual Source of Care
%
* p<.001
*
Access: Unmet Health Care NeedsBefore SCHIP and 1 Year After Enrollment
05
101520253035404550
Any Preven. Acute Specialty ED Meds
Before
After
%
All kids
*
**
*
*
*p<.05
Utilization: Percent with Visit/Med Before SCHIP and 1 Year After Enrollment
0102030405060708090
100
ED Specialty Acute Preventive Meds
Before
After
%
*p<.05
*
Quality:Proportion of Visits to USC
0%10%20%30%40%50%60%70%80%90%
100%
Before After
All
Most
Some
None
* p<.001
Quality:Parent Rating of Quality of Care
7.8
8.8
1
2
3
4
5
6
7
8
9
10
Overall Rating
Before
After
1-10, 10 is highest
* p<.001
*
Quality: CAHPS Ratings of Providers
7584 88
67
8893 92 89
0102030405060708090
100
Listens Explains Respects Time
Before
After
%
Yes
*p<.05
*
**
General Health Status
13
32
1713 12 12
0
5
10
15
20
25
30
35
40
Fair/ Poor Health Much Worry Less Healthy ThanOthers
Before
After
%
*p<.05
*
Problems Getting Care or MedsIf Asthma Attack
9
3
16
42 2
02468
101214161820
To USC To ED Medications
Before
After
%
Yes
p<.05
*
Problems Getting Care or MedsIf Asthma Attack
9
3
16
42 2
02468
101214161820
To USC To ED Medications
Before
After
%
Yes
p<.05
*
Reasons for Problems
-Cost (60%)
-Convenience (10%)
Quality Measures-- ASTHMABefore SCHIP and 1 Year After Enrollment
8
24
58
2
38
69
0102030405060708090
100
Asthma Tune-upVisit
Preventive Med Action Plan
Before
After
%
p = NS
Percent of Children with Moderate/Severe Asthma Who Had:
Change in Asthma or QualitySince Last Year (asked at T2)
0%10%20%30%40%50%60%70%80%90%
100%
Asthma Quality of Asthma Care
MuchWorse
Worse
Same
Better
MuchBetter
For ALL children with asthma
Reasons for Improvement in Asthma (Among the 75% Who Improved)
Decrease InSeverity
Better Quality of Asthma Care
Now has care 39% 58%
Medicines 26% 9%
Insurance now 1% 18%
Just less symptoms
7% 8%
Environment 7% 3%
Multivariate Results Adjustments for Demographics did not affect findings
The “SCHIP effect” remained significant for most measures Improvement in “unmet needs” only among Mild Asthma
For most other measures, similar pattern if Mild or Severe
“SCHIP Effect” ------Mild Asthma------ ------Severe Asthma------ Unadjusted Adjusted Unadjusted
Adjusted OR P OR P OR P OR P
Unmet Needs .2 .006 .2 .007 .6 .6 .7 .6
Most Visits to USC 11 <.001 15 <.001 12 <.001 12 <.001
Multivariate Results Adjustments for Demographics did not affect findings
The “SCHIP effect” remained significant for most measures Improvement in “unmet needs” only among Mild Asthma
For most other measures, similar pattern if Mild or Severe
“SCHIP Effect” ------Mild Asthma------ ------Severe Asthma------ Unadjusted Adjusted Unadjusted
Adjusted OR P OR P OR P OR P
Unmet Needs .2 .006 .2 .007 .6 .6 .7 .6
Most Visits to USC 11 <.001 15 <.001 12 <.001 12 <.001
Limitations and StrengthsLimitations:
Internal Validity Self-report (especially for quality measures) No perfect definition of asthma Possible regression to the mean
External Validity: One state SCHIP (and not Medicaid)
Strengths: First study of SCHIP & asthma, Large N, High follow-up rate
Conclusions Many children with asthma enrolled in SCHIP For children with asthma, during SCHIP:
Improved access to care and reduced unmet needs Change in pattern of care– more care at the USC Improved quality- general (Overall rating, CAHPS, continuity) Improved quality-asthma (Getting asthma care/meds, severity,
rating) Reduced parent worry Reasons for improvements- now getting care or meds
Still suboptimal quality on several measures in spite of SCHIP
Tune-up visits and preventive meds for severe asthma No improvement in general health status after SCHIP
Implications for Clinicians
Many children with asthma enrolling in SCHIP Their baseline quality of care is poor even
though most had a USC Better use of medical home is associated with
higher quality during SCHIP Need to do more to improve quality measures
Asthma tune-up visits, preventive meds for severe asthma
Implications for Health Plans
Many children with asthma enrolling in plans
Quality of asthma can improve with coverage but will not reach standards
Encourage clinicians to improve quality of care for children with asthma
Implications for Policy Makers
SCHIP reduces barriers to asthma care and improves access and quality of asthma care
Coverage of asthma medications is important SCHIP changed pattern of utilization
More use of USC, not more high-cost services (specialty, ED) SCHIP may cause higher initial costs for asthma SCHIP can have spill-over benefits: less parent
worry/stress SCHIP (?insurance) more likely to affect a condition-
specific measure than a global health status measure
Funders
Agency for Healthcare Research and Quality (AHRQ)
The David and Lucile Packard Foundation
Health Resources and Services Administration (HRSA)