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Improvement in Asthma Care After Enrollment in SCHIP

Improvement in Asthma Care After Enrollment in SCHIP. Peter G. Szilagyi MD, MPH 1,2 Andrew W. Dick PhD 2 Jonathan D. Klein MD, MPH 1,2 Laura P Shone, MSW, DrPH 1 Alina Bajorska MS 2 Jack Zwanziger PhD 4 Lorrie Yoos, PhD, PNP 1,3. 1 Dept. of Pediatrics

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Improvement in Asthma Care After Enrollment in SCHIP

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  1. 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, PNP1,3 1Dept. of Pediatrics 2Dept. Of Community & Preventive Medicine University of Rochester 3School of Nursing 4School of Public Health, Univ. of Chicago

  2. 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

  3. 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

  4. 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

  5. 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)

  6. 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

  7. Asthma Screener Methods* • During past year, did MD say child had asthma or • 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

  8. Asthma Screener: Prevalence Time Period# ChildrenAsthma 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

  9. Asthma Screener: Prevalence Time Period# ChildrenAsthma 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

  10. Asthma Screener: Prevalence Time Period# ChildrenAsthma 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

  11. 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

  12. 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%)

  13. 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

  14. Results: Demographics of 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

  15. Access: USCBefore SCHIP and 1 Year After Enrollment 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

  16. Access: Unmet Health Care NeedsBefore SCHIP and 1 Year After Enrollment % All kids * * * * * *p<.05

  17. Utilization: Percent with Visit/MedBefore SCHIP and 1 Year After Enrollment * % *p<.05

  18. Quality: Proportion of Visits to USC * p<.001

  19. Quality:Parent Rating of Quality of Care 1-10, 10 is highest * * p<.001

  20. Quality: CAHPS Ratings of Providers * * * % Yes *p<.05

  21. General Health Status % * *p<.05

  22. Problems Getting Care or MedsIf Asthma Attack % Yes * p<.05

  23. Problems Getting Care or MedsIf Asthma Attack Reasons for Problems -Cost (60%) -Convenience (10%) % Yes * p<.05

  24. Quality Measures-- ASTHMABefore SCHIP and 1 Year After Enrollment Percent of Children with Moderate/Severe Asthma Who Had: % p = NS

  25. Change in Asthma or QualitySince Last Year (asked at T2) For ALL children with asthma

  26. Reasons for Improvement in Asthma(Among the 75% Who Improved)

  27. 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 ORPORPORPORP Unmet Needs .2 .006 .2 .007 .6 .6 .7 .6 Most Visits to USC 11 <.001 15 <.001 12 <.001 12 <.001

  28. 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 ORPORPORPORP Unmet Needs .2 .006 .2 .007 .6 .6 .7 .6 Most Visits to USC 11 <.001 15 <.001 12 <.001 12 <.001

  29. Limitations and Strengths Limitations: • 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. Funders Agency for Healthcare Research and Quality (AHRQ) The David and Lucile Packard Foundation Health Resources and Services Administration (HRSA)

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