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
3School of Nursing
4School
of Public Health, Univ. of Chicago
University of Rochester
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

T1
Interview
Soon after enrollment
Measurement Period
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:
–
–
–

NYC, NYC environs, upstate urban, rural
0-5 yr, 6-11 yr, 12-18 yr
White NH, Black NH, Hispanic
2,644 first-time SCHIP enrollees
–
–

Region:
Age:
Race/ethnicity:
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 Identify
Asthma Severity*
- Frequency of asthma symptoms
- Limitations of activities
- Nighttime awakening due to asthma
“Mild”
*Questions adapted from NHLBI guidelines
“Moderate to severe”
Questions to Identify
Asthma Severity – at T1
- Frequency of asthma symptoms
- Limitations of activities
- Nighttime awakening due to asthma
334
“Mild ”
202 (60%)
“Moderate to Severe”
132 (40%)
Measures and Analyses
Measures




Access:
Use of care:
Quality measures:
Asthma-specific:
Usual Source of Care (USC), Unmet needs
Preventive, acute, specialty
% of visits to USC, parent ratings of quality
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: 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
Access: USC
Before SCHIP and 1 Year After Enrollment
Had Usual Source of Care
100
*
99
95
Accessibility Measures
(Children with Asthma)

90
%
80
Travel > ½ hour to MD

Before
After

29% to 6% ( p<.001)
Difficulty getting appt.

12% to 4% ( p<.01)
70
60
* p<.001

Wait > 15 minutes at visit

No improvement
Access: Unmet Health Care Needs
Before SCHIP and 1 Year After Enrollment
%
All
kids
50
45
40
35
30
25
20
15
10
5
0
*
Before
After
*
Any
Preven.
Acute
*
*
*
Specialty
ED
Meds
*p<.05
Utilization: Percent with Visit/Med
Before SCHIP and 1 Year After Enrollment
%
100
90
80
70
60
50
40
30
20
10
0
*
Before
After
ED
Specialty
Acute
Preventive
Meds
*p<.05
Quality:
Proportion of Visits to USC
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
All
Most
Some
None
Before
After
* p<.001
Quality:
Parent Rating of Quality of Care
10
9
8
7
6
1-10, 10 is highest
8.8
7.8
*
Before
5
4
3
2
After
1
Overall Rating
* p<.001
Quality:
CAHPS Ratings of Providers
%
Yes
100
90
80
70
60
50
40
30
20
10
0
*
88
75
* 93
84
88
92
89
*
67
Before
After
Listens
Explains
Respects
Time
*p<.05
General Health Status
40
35
32
30
%
25
*
20
15
13
13
12
17
Before
12
After
10
5
0
Fair/Poor Health
Much Worry
Less Healthy Than
Others
*p<.05
Problems Getting Care or Meds
If Asthma Attack
%
Yes
20
18
16
14
12
10
8
6
4
2
0
16
Before
9
After
4
To USC
3
2
To ED
*
2
Medications
p<.05
Problems Getting Care or Meds
If Asthma Attack
Reasons for Problems
-Cost (60%)
-Convenience (10%)
%
Yes
20
18
16
14
12
10
8
6
4
2
0
16
Before
9
After
4
To USC
3
2
To ED
*
2
Medications
p<.05
Quality Measures-- ASTHMA
Before SCHIP and 1 Year After Enrollment
Percent of Children with Moderate/Severe Asthma Who Had:
%
100
90
80
70
60
50
40
30
20
10
0
69
58
Before
After
38
24
8
2
Asthma Tune-up
Visit
Preventive Med
Action Plan
p = NS
Change in Asthma or Quality
Since Last Year (asked at T2)
For ALL children with asthma
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Much
Worse
Worse
Same
Better
Asthma
Quality of Asthma Care
Much
Better
Reasons for Improvement in Asthma
(Among the 75% Who Improved)
Decrease In
Severity
39%
Better Quality of
Asthma Care
Medicines
26%
9%
Insurance now
1%
18%
Just less symptoms
7%
8%
Environment
7%
3%
Now has care
58%
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------
Unmet Needs
Most Visits to USC
Unadjusted
OR
P
.2
.006
Adjusted
OR
P
.2
.007
------Severe Asthma-----Unadjusted
Adjusted
OR
P
OR
P
.6
.6
.7
.6
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------
Unmet Needs
Most Visits to USC
Unadjusted
OR
P
.2
.006
Adjusted
OR
P
.2
.007
------Severe Asthma-----Unadjusted
Adjusted
OR
P
OR
P
.6
.6
.7
.6
11 <.001
15 <.001
12
<.001
12 <.001
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
Conclusions


Many children with asthma enrolled in SCHIP
For children with asthma, during SCHIP:







Still suboptimal quality on several measures in spite of 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
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 conditionspecific 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)