Do School-Based Health Centers Provide Adequate Asthma Care?

Do School-Based Health Centers Provide Adequate Asthma Care? Tosan Oruwariye, Mayris P. Webber, Phillip Ozuah

ABSTRACT: School-based health centers (SBHCs) are increasingly charged with providing primary care services including asthma cure. This study assessed SBHC provider adherence to the National Heart, Lung, and Blood Institute (NHLB1)asthma care guidelines and the association among provider adherence, patient characteristics. and asthma outcomes. A cross-sectional .study design was used to assess SBHC chart data from 415 children with asthma attending four inner-city elementary schools (K-5) in the Bronx, NY. Asthma symptoms, peukjlow use. follow-up visits. and referrals to asthma specialists were documented in the charts of 6O%, 51%, 22%, and 3% of subjects, respectively. Thirty-three percent of charts had SBHC clinician-documented severity classifications. of which 70% had appropriate medications prescribed. Asthma education and an asthma plan were documented in 18% and 10% of charts. respectively. Environmental triggers and tobacco e.uposures were documented in 71% and 49% of charts, r-espectively.Older children (> 8 years) were more likely to have documentation of peak flow use for asthma management, asthma education,follow-up visits, and written asthma plans, whereas younger children (< 8 years) were more likely to miss more days of school (all p < ,051. Overall, provider adherence to NHLBI guidelines was inadequate, with adherence somewhat betterf o r older children. (J Sch Health.

2003;73(5):186-190)

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sthma, the most common chronic illness affecting children, is associated with more than 570,000 emergency department visits and 3 million office visits annually for young children.',2Asthma is the leading chronic illness cause of school absenteeism with direct medical expenditures estimated at $500 million for children under age 17.'" Children in the inner city are disproportionately affected when compared to the general population, with prevalence and mortality rates two and five times the national average,

In 1997, NHLBI revised its recommendation for asthma care by health professionals. The Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma focused on processes recognized as components of highquality asthma care, including 1) periodic physiologic assessment and monitoring of asthma symptoms; 2) proper use of medication; 3) patient education; and 4) control of factors contributing to asthma severity.' In 2002, NHLBI updated its recommendations on: 1) medication use, 2) monitoring, and 3) pre~ention.~ Though proper outpatient asthma management reduces asthma morbidity,",' previous studies noted the variability in asthma care and difficulties in attaining optimal outpatient asthma management, despite the NHLBI Poor provider adherence to the guidelines, especially in busy clinics, frequently underfunded and understaffed, contributes to the problem.""* Limited parental access to quality care, difficulties in adhering to the child's medication regimen, and managing the child's illness, especially in inner-city communities with multiple social and economic challenges, also contribute to poor outpatient asthma management. I 3 , l 4 Tosan Oruwariye, M D , M P H , M S c , Assistant Professor, Clinical Pediatrics, Albert Einstein College of MedicinelChildren's Hospital at Montefore, 3444 Kossuth Ave., DTC Bldg.,firstjloor, Bronx, NY 10467; ( t o r u w a r i y e ~ a o l . ~ o mMayris ); P . Webber, DrPH, Associate Professor, Dept. of Epidemiology and Population Health Medicine, Montefiore Medical CenterlAlbert Einstein College of Medicine, I 1 1 E. 210th St., Bronx, NY 10467; (mwebber~montefore.org):and Phillip Ozuah, MD, PhD, Associate Professor, Clinical Pediatrics, Albert Einstein College of MedicinelChildren's Hospital at Montefore, 1I1 E. 210th St., Bronx, NY 10467; ([email protected]). Presented in part at the annual meeting of the Pediatric Academic Societies in Baltimore, MD, on May 5 , 2002. This work was supported by funding from the Agency for Healthcare Research and Quality, grant # R18 HS10136. This article was submitted August 21, 2002, and revised and accepted for publication February 18,2003.

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School-based health centers (SBHCs) improve access to health care in inner-city communities and provide various levels of service that include primary care, acute care, and health education to more than 1 million children nationwide.lS.16 The Montefiore School Health Program (MSHP) has 1 I SBHCs that provide comprehensive services to more than 13,000 children in the Bronx, New York City. About 40% of the children in this setting have no other regular source of primary care. Because SBHCs have become important sites for intervening in asthma care," a need exists to standardize asthma care received by children at these sites by following recommendations of the NHLBI guidelines. The first step toward standardization of asthma care involved assessing SBHC provider adherence to NHLBI asthma care guidelines and examining the association among provider adherence, patient demographics, hospitalizations, emergency department visits, and school absenteeism.

METHODS Participants

The cross-sectional study was conducted at four elementary schools in the Bronx, NY, with SBHCs that offer comprehensive primary care services and are affiliated with a tertiary care medical center. These SBHCs are open during school hours (7 am - 3 pm) and are staffed by pediatricians, nurse practitioners, licensed practical nurses, mental health professionals, health educators, and ancillary staff. Parental consent is required for treatment. Children who had at least one asthma visit at any of the four SBHCs during the 1999-2000 school year, and were enrolled in school for more than one-half the school year, were eligible for the study (N = 415). Data Collection

Chart Reviews. All active charts of children enrolled at any of the four SBHC in the four elementary (K-5) schools were reviewed, and data were abstracted from those who received asthma care at the SBHC one or more times during the 1999-2000 school year (N = 415). Chart reviews were conducted in July and August 2001 using a standardized data collection instrument based on NHLBI guidelines. Data collected were categorized into four components of the NHLBI guidelines: 1) Periodic physiologic assessment,

2 ) Proper use of medications, 3) Patient education, and 4) Factors that worsen asthma. Information on age, gender, school of attendance, provider training (MD or NP) and number of asthma visits also was abstracted from the charts. Four reviewers were trained to use the data abstraction tool. All four reviewers abstracted data from each chart. Abstracts were reviewed for concordance and consensus reached on each chart. If consensus was not reached, a fifth reviewer (pediatrician) served as the final judge for discordant findings. Parent Surveys. Parental caretakers of the children completed bilingual surveys between January and March 2000. Surveys were sent home with the children, and three or more attempts were made to obtain a response from each child’s family. Small gifts were given to each child for returning a survey. Information collected from the parent survey included the use of health care services including emergency department visits and hospitalizations for asthma in the past 12 months.I8 Educational Records. Absenteeism data were collected from each school at the end of the 1999-2000 school year. Information collected included number of days each student was enrolled at the school and number of days absent. Study Measures Since NHLBI guidelines do not specify measures to assess quality of asthma care, methodology reported by Diette et ally that reflects adequate asthma care was used. The main process measure was SBHC chart documentation of the four components of the NHLBI guidelines: 1 ) Periodic physiologic assessment and monitoring of asthma, 2) Appropriateness of prescribed medications, 3) Patient education, and 4) Factors that worsen asthma. Care indicators in each NHLBI component were assessed as either present or absent. The SBHC clinician’s assigned severity classification, or documented severity classification based on spirometry results for children referred to a pulmonologist, was the accepted “severity classification.” “Appropriateness of medications” was defined as prescribing daily anti-inflammatory medications for patients with persistent asthma. Documentation of “symptoms” was considered adequate if documentation existed for the presence or absence of at least one of six symptoms: 1) wheezing, 2) chest pain or tightness, 3) coughing especially at night, 4) shortness of breath, 5 ) colds that lasts more than 10 days, and 6) exercise-induced shortness of breath. “Peak flow” use in asthma management was defined as the presence of any documentation of medication adjustment for different peak flow measurements. Asthma “follow up” was defined as any documentation of routine quarterly asthma visits for children with persistent asthma. The Institutional Review Board of Montefiore Medical Center approved this study. Data Analysis Researchers used bivariate analyses for proportions, with the Mantel-Haenszel estimation of odds ratio (OR) with 95% confidence intervals, to examine the association among adherence to different NHLBI components and patient characteristics, hospitalizations, and emergency department use. Age was stratified into two groups (< eight years and 2 eight years). Student’s t-test was used to exam-

ine the difference in school absenteeism between the two age groups. Children assigned a severity classification by their provider were dichotomized into two groups (persistent or intermittent), and adequacy of prescribed medications was assessed for each group. The p-value for statistical significance was set at < .05. All analyses were performed using SPSS version 10.0 software.

RESULTS The process identified 568 charts of children with asthma from the four SBHCs. Some 415 children met the eligibility criteria for study and also had health care utilization information from the parent survey. The children were mostly Hispanic (55%), 50.4% male, with a mean age of 8.5 years. Only 133 patients (32%) had a SBHC clinician-assigned asthma severity classification. Of these patients, 69% (92/133) were on appropriate medications for their classification. Of those with mild intermittent severity class, 74.2% (72/97) had appropriate medications. For those classified as having persistent asthma, only 55.6% (20/36) were on appropriate medications (OR = 0.43, 95% CI 0.19 0.96). Sixteen children were referred to a pulmonologist for spirometry testing. However, only three kept their pulmonology appointments. Spirometry testing documented persistent asthma in all, but only two received appropriate medication. Overall, the highest adherence was in assessment of environmental trigger (Table 1). Provider Adherence by Patient Age Older children (> 8 years of age) were more likely to have documentation of peak flow use for asthma management than younger children (< 8 years of age) (OR 1.9, CI 1.3 - 2.8). Older children also were more likely to have follow-up visits (OR 2.6, CI 1.5 - 4.6), asthma education (OR 1.7, CI 1.0 - 2.9), and written asthma plans (OR 2.3, CI 1.0 - 4.9). Though statistical significance was not attained on other associations examined, a trend emerged toward increasing provider adherence with older children (Table 2). Provider Adherence and Asthma Hospitalization Twenty-seven children (6.5%) were hospitalized at least once for asthma in the past year. No statistically significant associations were noted between provider adherence and hospitalization. Provider Adherence and Emergency Department Visits Overall, one-third of parents reported that subjects had been to the emergency department for asthma in the past year (33.7%, 1401415). Use of peak flow meters to manage asthma was associated with a greater likelihood of having had one or more emergency department visits in the past year (OR 1.53, CI 1.02 - 2.32), as well as having been referred t o a specialist (OR 3.65, CI 1.05 - 12.6). Documentation of tobacco exposure was associated with a greater likelihood of having one or more emergency department visits in the past year (OR 1.58, CI 1.05 - 2.34).

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Provider Adherence and School Absenteeism Absenteeism data were available for 267 children. Overall, mean number of full days of school missed was 17.6 (SD ? 12.2). No associations existed between provider adherence and n u m b e r of school d a y s absent. However, younger children (< 8) had more school absences than older children (> 8 years) (20.0 -+ 11.8 vs. 16.1 ? 12.2, p < .002). SBHC Asthma Visits Overall, the mean number of asthma visits for children with asthma at a SBHC was 4.5 (SD -+ 13.4). For children with a SBHC clinician-assigned severity classification, those with persistent asthma had more SBHC asthma visits compared to children with intermittent asthma (16.0 ? 11.8 versus 4.6 2 7.8, p < .03).

ence across all four components of the NHLBI guidelines, an issue that takes on great significance because about 40% of children who use these SBHCs have no other regular source of primary care. The wide disparity in adherence to different components of the guidelines underscores a need to evaluate factors that facilitate or impede adherence in this setting, and to clarify components providers feel are more relevant to asthma care in their practice. Age-related differences in provider adherence, specifically why adherence to certain components was worse for Table 2 Relationship Between Provider Adherence to the NHLBI Guidelines and the Age of the Child Indicator PresentlAbsent % with Present Response Shown Age of Children N = 415 (%)

DISCUSSION This study confirmed inadequate SBHC provider adher-

Table 1 Overall Provider Adherence to the NHLBI Guidelines

Care Indicators Abstracted from Chart

N = 415 Patients (%) Indicator PresentlAbsent % with Present Response Shown

Component 1: Physiologic Assessment Documentationof: Asthma symptoms Peak flow meter use for asthma management Quarterly follow-up visits Specialists referrals Component 2: Proper Medications Prescribed Appropriate medications prescribed for classification

250 (60.2) 211 (50.8) 15/36 (41.6) * 2/16 (12.5) y y

92/133 (70.8) *

Component 3: Patient Education Documentationof: Asthma plan Asthma education

40 (9.6) 74 (17.8)

Component 4 Factors That Worsen Asthma Documentation of: Environmental triggers Tobacco exposure

293 (70.6) 203 (48.9)

* = follow-up visits for subjects with persistent asthma. * = referrals to specialists for patients with moderatefsevere persistent asthma.

* = appropriate medications for subjects with a severity classification.

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Care Indicators Abstracted from Chart Component 1: Physiologic Assessment Asthma symptoms Peak flow meter use FOIIOW-UP visits Specialists referrals

~8yrs N = 179

;r 8yrs

N=236

Odds Ratio (Confidence IntervaI)

89 (56.3%)

161 (62.9%)

1.08 (0.65-1.8)

65 (41.1%)

146 (57.0%)

1.92 (1.3-2.8)

20 (12.7%)

71 (27.7%)

2.6 (1.6-4.6) *

4 (2.5%)

7 (2.7%)

1.O (0.4-3.7)

89 (34.8%)

1.4 (0.9-2.1)

64 (71.9%)

1.5 (0.7-3.2)

31 (12.1 %)

2.3 (1 .O-4.9)

53 (20.7%)

1.7 (1 .O-2.9) *

Component 2: Proper Medications Severity classification 44 (27.8%) Appropriate medications 28 (63.6%) Component 3: Patient Education Asthma plan 9 (5.7%) Asthma 22 (13.3%) education

Component 4: Factors That Worsen Asthma Environmental triggers 106 (67.1 %) 187 (73.0%) Tobacco exposure 73 (46.2%) 130 (50.8%)

1.3 (0.8-2.1) 1.2 (0.8-1.8)

* Mantel-Haenszel estimation of odds ratio (OR) with 95% confidence intervals, significance p c .05.

younger children, needs further evaluation. Age eight was selected as the cut-off point for the analysis, because the asthma management program in this setting revolves around the curriculum used for asthma education in the schools (Open Airways for Schools) which is validated for children age eight and older. Use of this curriculum also provides opportunities for frequent interaction between providers and older children, resulting in opportunities to improve all aspects of asthma care for these children and possibly influence provider adherence. Another plausible explanation about age-related disparities in this setting suggests that younger children a r e disadvantaged in expressing and quantifying their asthma symptoms. This situation is particularly problematic in school-based health centers, because parents are not usually present when care is initiated, and they have to be contacted when the child visits the clinic. In addition, Diette et ally noted age-related differences in compliance to the guidelines in a group of primarily Caucasian children in managed care, suggesting that the finding is not restricted to this setting. Emergency department visits are high in this setting as in other inner-city communities,’,6 and might reflect limited availability of care after school hours at SBHCs, a finding that deserves further research. A significant association was noted between use of peak flow meters to manage asthma and emergency department visits. Children who visit emergency departments might be instructed by emergency department personnel in peak flow use, or they also might be instructed by SBHC providers as part of the asthma education program in schools. This finding suggests a need to explore further the relationship between peak flow use and emergency department use. Similarly, the relationship between emergency department visits and referrals to asthma specialists remains unclear because researchers do not know if emergency department providers, other outside providers, or school providers initiate referrals to asthma specialists. The relationship between being referred to a specialist and emergency department use undoubtedly reflects the severity of the child’s illness; it also may suggest that some children fail even specialist management. The finding that tobacco exposure is associated with an increased likelihood of an emergency department visit underscores the need to address environmental tobacco smoke exposure in children with asthma and to integrate smoking cessation counseling into routine asthma care during follow-up visits with the family: Finally, children with persistent asthma received more inappropriate medications for their classification, a finding also noted in previous studies in other primary care settings,’*suggesting a need for ongoing provider education about this component of the guidelines. This study has several limitations. First, the crosssectional design of the study limited the ability to make inferences regarding causality. Second, chart reviews do not always reflect clinician practices. However, data on provider-prescribed medication regimens generally are accurate, and the similarity of these results with other studies gives credence to these findings.’ Third, use of SBHC clinician-assigned severity classifications rather than spirometry-based severity classification as recommended by the NHLBI guidelines might limit reliability of these data. However, other studies show that providers classify

asthma severity appropriately if they have all relevant clinical information.’3Peak flow meter measurements are used primarily to increase patient and caregiver awareness of disease status and facilitate provider-patient communication, rather than to replace spirometry. Also, in this setting, due to the expense and expertise required, children are referred to both a pulmonologist and allergist for testing. However, in consultation with pulmonologists, and after review of the practices of both primary care and specialist providers caring for children with asthma, there appears to be agreement that patient-reported symptoms provide the primary guide for their periodic evaluations for children with asthma, with spirometry used as an important adjunct. This finding suggests that use of spirometry for routine monitoring of patients with asthma in school settings has yet to be clearly defined. Finally, care at SBHCs is not typical of primary care clinics because children and teachers initiate acute care visits. Parents are contacted on the child’s arrival at the SBHC with information obtained from parents by telephone or when they arrive at the center, and actual care initiated based on symptoms reported by children before their parents arrive. However, irrespective of the structure and process by which care is obtained, SBHC providers must offer quality care that meets national standards if they assume the role of primary care providers. The challenge is to develop innovative strategies that help school-based providers attain this objective.

CONCLUSION SBHCs have increased access to health care in inner-city communities where they now are charged with providing comprehensive primary care services. As SBHCs change their traditional role, providers in these settings will be required to practice according to national standards, if they seek to be considered a credible source of high-quality primary care. This study identified a need for creative strategies to care for children with a chronic illness like asthma in a school setting where parents are often not present, but where children can be seen for regular follow up. Furthermore, strengths and weaknesses of asthma management in SBHCs were identified. Further research is needed to identify factors that facilitate adherence to NHLBI guidelines in this setting where significant opportunities exist to improve outpatient asthma management. 1

References 1 . National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report No.2. NIH publication 97-4051; July 1997. 2. Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for Asthma - United States, 1960-1995. Atlanta, Ga: Centers for Disease Control and Prevention; 1998;47:1-28. 3. Newachek PW, Halfon N. Prevalence, impact, and trends in childhood disability due to asthma. Arch Pediutr Adolesc Med. 2000,154:287-293. 4. Evans R. Prevalence, morbidity, and mortality of asthma in the inner city. Pediatr Allergy Immunol. 1994;8(3):171-177 5. Cam W, Zeitel L, Weiss K. Variations in asthma hospitalizations and deaths in New York City. Am J Public Health. 1992;82:59-65 6. Crain EF, Weiss KB, Bijur PE, et al. An estimate of the prevalence of asthma and wheezing among inner city children. Pediarrics. 1994;94:356-362 7. National Asthma Education and Prevention Program Panel Report. Guidelines for the Diagnosis and Management of Asthma - Updates on Selected Topics 2002. NIH publication 02-5075; July 2002.

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8. Lieu TA, Quesenberry CP Jr, et al. Outpatient management practices associated with reduced risk of pediatric asthma hospitalization. Pediatrics. 1997;100(3):334-342 9. Pauley TR,Magee MJ, Cury JD. Pharmacist-managed, physiciandirected asthma management program reduces emergency department visits. Ann Pharmacotherapy. 1995;29:5-9. 10.Crain EF, Weiss KB, Fagan MJ. Pediatric asthma care in US emergency departments (Current Practice in the context of the National Institute of Health Guidelines). Arch Pediatr Adoles Med. 1995;1492393-901. 1 1. Finkelstein JA, Lozano P, Shulruff R, et al. Self-reported physician practices for children with asthma: are national guidelines followed? Pediatrics. 2000; 106(4suppl):886-896. 12. Doerschug KC, Peterson MW, Dayton CS, Kline JN. Asthma guidelines: an assessment of physician understanding and practice. A m J Respir Crit Care Med. 1999;159:1735-1740. 13. Halteman JS, Aligne CA, Auinger P, McBride JT, Szilagyi PG. Inadequate therapy for asthma among children in the United States. Pediatrics. 2000; 105:272-276.

14. Leickly FE, Wade SL, Crain E, Kruzon-Moran D, Wright EC, Evans R 111. Self-reported management behavior and barriers to care after an emergency department visit by inner city children with asthma. Pediatrics 1998 May;101(5):E8. 15. Morone JA, Kilbreth EH, Langwell KM. Back to school: a health care strategy for youth. Health Afsirs. 2001;20: 122-136. 16. http://www .healthinschools.org/pubs/access/Winter200 1 .asp 17. Calabrese BJ, Nanda JP, Huss K, et al. Asthma knowledge, roles, functions, and educational needs of school nurses. J Sch Health. l999;69(6):233-238. 18. Webber MP, Carpiniello KE, Oruwariye T, Appel DA. Prevalence of asthma and asthma-like symptoms in inner-city elementary schoolchildren. Pediatr Pulmonol. 2002;34: 105-1 11. 19. Diette GB, Skinner EA, Markson EL, et al. Consistency of care with national guidelines for children with asthma in managed care. J Pediatrics. 2001;138( 1):59-64.

SafeUSA Launches “Best Practices of Youth Violence Prevention: A Sourcebook for Community Action”

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