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)