Elementary School–Based Health Centers and Access to Preventive and Asthma-Related Care Among Publicly Insured Children With Asthma in Georgia

Abstract

Objectives

We assessed the effects of 3 new elementary school–based health centers (SBHCs) in disparate Georgia communities—predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural—on asthma case management among children insured by Medicaid/Children’s Health Insurance Program (CHIP).

Methods

We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child–school year.

Results

We found an increase of about 19 (P = .01) to 33 (P < .001) percentage points in the probability of having ≥3 asthma-related visits per child–school year and an increase of about 22 (P = .003) to 24 (P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 (P = .01) to 29 (P < .001) percentage-point increase in receipt of asthma-control medication and a 15 (P = .03) to 30 (P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC.

Conclusion

Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

Keywords

asthma ethnic disparities health care delivery health disparities health economics

Pediatric asthma, the most common serious lung disease among children and adolescents in the United States, affecting approximately 6 million children and adolescents in 2001-2016,¹ is a leading cause of missed school days.² In 2017, asthma was the most common cause of potentially preventable pediatric stays (81.8 per 100 000 population), generating aggregated costs of $278.1 million.³ In 2017, the rate of pediatric hospital stays per 100 000 population was higher among males than among females aged 2-17 years (96.3 vs 66.6) and higher among non-Hispanic Black children (217.9) than among children of any other race/ethnicity (range, 43-74).³

Although asthma cannot be cured, it can be managed through proper medication and recognition of symptoms and triggers. Studies on the effects of asthma management programs showed improvements in economic and health outcomes.^4
-6 Furthermore, equal access to asthma care and good management practices are effective at reducing racial/ethnic disparities.⁷ Yet fewer than half of children adhere to their asthma medication regimen.⁸ These studies highlight the importance of evaluating new policies aimed at improving access to, quality of, and adherence to asthma management among children.

School-based health centers (SBHCs) are physically located in or near schools to provide health care to students. At a minimum, these clinics provide primary health care and, whenever possible, mental, vision, and oral health services. Optimal core staff includes a pediatrician, a nurse practitioner or physician assistant, a social worker/mental health counselor, a school nurse, a medical assistant, and a community outreach worker. Asthma interventions based in SBHCs may improve children’s access to asthma-related health care and/or reduce health care–related costs. Most previous studies, often using pre–post analysis and, sometimes, a comparison group (ie, children without access to, or use of, an SBHC), show that SBHCs improve the identification of children at high risk of asthma. Several evaluations of children diagnosed with asthma concluded that children with access to an SBHC had fewer emergency department (ED) visits, lower hospitalization rates,^9

-14 and fewer missed school days, when compared with children without access to an SBHC.^15
-17

In a study published in 2001, surveyed parents of children using SBHC resources reported reductions in their complaints about asthma and related disruptions for family plans,¹⁰ and in a study published in 2008, children in SBHC-related care had significant monthly decreases in activity restrictions caused by asthma.¹¹ Health improvements can translate into cost savings: a study published in 2005 reported a reduction in hospitalization costs among children with asthma, from $1150 to $180 per child, after the opening of an SBHC.¹⁴ Still, researchers highlight challenges in disease management programs and concerns about how to engage children and families in appropriate follow-up care for asthma¹⁸ and ensure that schools adopt and maintain successful interventions.¹⁹

Substantial gaps in the literature include information on adequacy of asthma care in SBHCs, especially in SBHCs that serve elementary (kindergarten–grade 5) schools. To our knowledge, only Oruwariye et al²⁰ in 2003 questioned whether SBHCs were adhering to the asthma care guidelines of the National Heart, Lung, and Blood Institute.²¹ They found that only 32% of children with asthma in SBHCs in 4 elementary schools in the Bronx, New York, were assigned a severity classification in their medical records, and only 69% were taking appropriate medications. In that study, older children (aged >8 years) were more likely than younger children to have follow-up visits, asthma education, and written asthma plans. These patterns are problematic because some children served in SBHCs have no other regular source of primary care.

A study published in 2000 in Georgia²² found that children aged 4-12 years served in SBHCs had significantly lower Medicaid/Children’s Health Insurance Program (CHIP) expenses for inpatient care, non-ED transportation, drugs, and ED visits in the second year of the SBHC than children without access to an SBHC. However, the lower costs only held for inpatient care for children with asthma in the first year of the SBHC and for drugs in the second year of the SBHC, and that study was conducted before the mandated enrollment in 2006 of children insured by Medicaid/CHIP into care management organizations (CMOs) in Georgia.²³

From 2013 to 2017, 3 elementary schools participated in a pilot program in Georgia, a state with disparities in health care access among children in low-income families. The program aimed to determine whether SBHCs using federally qualified health centers (FQHCs) as their umbrella organization would, with consulting support from leaders of the previously successful model, develop a sustainable service. The Zeist Foundation and the Healthcare Georgia Foundation provided funding.²⁴ Schools were chosen competitively from more than 30 applicant communities on the basis of documented community support, readiness to host an FQHC-run SBHC, and willingness to be mentored for 2 years while establishing sustainability. Recognizing that the disparate geographic and demographic populations represented by these pilot communities could comprise a natural experiment, we obtained funding from the National Institute on Minority Health and Health Disparities to examine the overall adequacy of care at the 3 new SBHCs. We found that the SBHCs had positive overall effects on preventive care for publicly insured children.²⁵ The objective of this further analysis was to assess whether implementation of the 3 SBHCs improved the case management of children with asthma who were enrolled in Medicaid/CHIP.

Methods

We used linked claims data to examine the effects of SBHCs that were fully implemented by the beginning of the 2013-2014 school year on access to preventive and asthma-related care for children enrolled in Medicaid/CHIP. We used a quasi-experimental difference-in-differences design to measure differences in the change in treatment of Medicaid/CHIP-enrolled children with asthma who had access to an SBHC and a comparison sample of Medicaid/CHIP-enrolled children with asthma who did not have access to an SBHC in the school years before (2011-2013) and after (2013-2018) SBHC implementation. Our main analysis identified children as having asthma in the school years before implementation whom we followed into the post-implementation period. To be included, a child had to be enrolled in Georgia’s Medicaid/CHIP program for ≥1 month in both the pre-SBHC implementation period and post-SBHC implementation period. The Emory University Institutional Review Board approved these analyses, which we conducted in 2020. In a secondary analysis, we identified children who met the inclusion criteria for enrollment in the Medicaid/CHIP program for ≥1 month in both the pre- and post-SBHC implementation periods but were newly diagnosed with asthma in the post-implementation period.

The 3 elementary schools that participated in the pilot program were in Fulton County, Dougherty County, and Catoosa County. The participating schools were in communities that differed in racial/ethnic composition and urban–rural environment (Table 1). In Fulton County, Lake Forest primarily served a suburban Hispanic population (90.9%, hereinafter referred to as treatment/urban/Hispanic); in Dougherty County, Turner primarily served a non-Hispanic Black population (90.7%) in a small city (hereinafter referred to as treatment/small city/non-Hispanic Black); and in Catoosa County, Tiger Creek primarily served a rural non-Hispanic White population (9.1% racial/ethnic minority, hereinafter referred to as treatment/rural/non-Hispanic White). We pragmatically selected comparison schools (in Fulton County, Mimosa; Dougherty County, Northside; and Catoosa County, West Side) that were in the same county and had a similar racial/ethnic composition, percentage of students who were eligible for free and reduced-price lunch, and student–teacher ratio.²⁶

Table 1

Characteristics of schools with and without an SBHC in 3 counties in Georgia, in a study on the use of SBHCs among Medicaid/CHIP-enrolled children with asthma, 2018-2019 and 2019-2020 school years^a

Characteristic	Fulton County		Dougherty County		Catoosa County
Characteristic	SBHC	Comparison (no SBHC)	SBHC	Comparison (no SBHC)	SBHC	Comparison (no SBHC)
School name	Lake Forest	Mimosa	Turner	Northside	Tiger Creek	West Side
Environment of community in which school was located
Metropolitan suburban	x	x
Small city/small suburban			x	x
Rural fringe/suburban					x	x
Categorized in study as . . .	Urban/Hispanic		Small city/non-Hispanic Black		Rural/non-Hispanic White
Zip code	30328	30076	31705	31701	30755	30741
Student population
Grades	PK-5	PK-5	PK-5	PK-5	PK-5	PK-5
No. of students enrolled	806	781	494	407	484	513
% Non-Hispanic Black	4.1	12.0	90.7	90.7	1.4	3.3
% Hispanic	90.9	79.9	4.5	0.7	3.9	9.6
% Racial/ethnic minority	96.5	94.4	96.4	95.1	9.1	21.4
% Eligible for free or reduced-price lunch	100.0	80.2	100.0	100.0	47.1	66.3
School
Student–teacher ratio	11.3	11.6	14.1	15.7	12.0	13.0
Title I school	Yes	Yes	Yes	Yes	Yes	Yes
Title I schoolwide program	Yes	Yes	Yes	Yes	Yes	Yes

Abbreviations: CHIP, Children’s Health Insurance Program; PK, prekindergarten; SBHC, school-based health center.

^aData source: National Center for Education Statistics.²⁶

The SBHCs in the pilot program offered comprehensive medical and mental health services, including health promotion and prevention and treatment of acute and chronic health conditions. Staff members included a medical assistant and an advanced practice provider with physician oversight. The treatment/urban/Hispanic school and treatment/small city/non-Hispanic Black school had on-site mental health providers. The treatment/rural/non-Hispanic White school and treatment/small city/non-Hispanic Black school offered on-site dental services, and the treatment/urban/Hispanic school had a health educator.

Data Collection

We obtained data on claims/encounters and enrollment for children aged 5-12 years ever enrolled in Georgia Medicaid/CHIP from the Georgia Department of Community Health²³ through its vendor (IBM Watson Health Analytics). Data consisted of all inpatient, outpatient, professional, and pharmaceutical encounters; dates of service; dollar amounts billed/paid to individual health care providers by the CMOs; diagnosis codes, procedure codes, and National Drug Codes; and health care provider identification numbers. Health care provider and enrollment files included providers’ place of service and children’s residential addresses. We created analytic files for August through May of school years 2011-2012 through 2017-2018. We defined the pre-implementation period as 2011-2013 and the post-implementation period as 2013-2018. Our study population was aged 5-12 years during the pre-implementation period and post-implementation period in both the treatment and comparison areas. In the pre-implementation period, the youngest child was aged 5 and no child was older than age 11; a child older than age 12 in the post-implementation period aged out of our sample. We used unique encrypted identification numbers to follow individual children insured by Medicaid/CHIP.

Children with asthma were defined as children who had a principal diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 493 or 2 secondary diagnoses of ICD-9-CM code 493 ≥30 days apart²⁷; we used ICD-9-CM code 493 before October 1, 2015, and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code J45²⁸ after September 30, 2015. We also conducted a subanalysis of children newly diagnosed with asthma in the post-implementation period. For these newly diagnosed children, we used the more detailed ICD-10-CM coding to measure moderate or severe asthma (ICD-10-CM codes J45.40, J45.41, J45.42, J45.50, J45.51, and J45.52).

For the purposes of this article, we defined district as the geographic area from which students were drawn to attend a specific school. We identified children in school districts with a new SBHC by using children’s residential addresses and the ArcGIS version 10.6.1 (Esri) geocoder database combined with a map of the elementary-level school districts’ coordinates. We merged school names with Medicaid/CHIP data to identify children in the treatment group, defined as those with access to an SBHC, and the children in the comparison group, defined as those without access to an SBHC. We identified children who used their SBHCs in the post-implementation period by (1) health care provider identification numbers on the claims/encounters whose place of service was the SBHC, (2) Medicaid/CHIP identification numbers of children reported directly by the SBHCs (treatment/urban/Hispanic and treatment/rural/non-Hispanic White), or (3) health care provider identification numbers only (treatment/small city/non-Hispanic Black).

The unit of observation was child–school year, and each child had to be in school at least 1 year before implementation of the SBHCs (school years 2011-2012 and 2012-2013) and 1 year after implementation (2013-2014 through 2017-2018). We flagged pre-implementation and post-implementation years to create a pre–post independent variable for analysis. We identified 193 unique children with asthma in SBHC school districts for a total of 333 child–school year observations in the pre-implementation period and 525 child–school year observations in the post-implementation period. Fifty-five of the 193 children (34%) used an SBHC. The 163 unique children with asthma in comparison school districts led to 270 child–school year observations pre-implementation and 478 child–school year observations post-implementation.

Measures

We analyzed receipt of the following 8 preventive services: well-child/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) visits; influenza immunization; services for management of asthma (≥3 visits during the school year, asthma-relief medication, asthma-control medication, ≥2 asthma-control medications); any ED visit (any diagnosis); and number of ED visits. We measured the receipt of services by using ICD-9-CM and ICD-10-CM codes, Current Procedural Terminology codes, category of service (eg, EPSDT visit), and National Drug Codes.

We used multivariate logistic regression models to test whether SBHCs were associated with a differential change from pre-implementation to post-implementation in the receipt of care among Medicaid/CHIP-enrolled children with asthma in school districts with and without an SBHC. This difference-in-differences approach measures the average marginal effect of an intervention.²⁹ A marginal effect is interpreted as the percentage-point difference in the outcome (eg, preventive care) for the treatment (ie, SBHC) and comparison (ie, no SBHC) groups.³⁰

Given the differences in the sociodemographic characteristics of the children across school districts and our earlier finding of different effects across the SBHCs,²⁵ we controlled for sociodemographic characteristics using data across all schools and by individual treatment and comparison school. We controlled for the following: (1) age at beginning (August) of the school year; (2) race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, non-Hispanic “other” [Asian, Pacific Islander, Native American, or “other”]); (3) Medicaid eligibility category, which indirectly reflects income levels (low-income Medicaid, <50% of the federal poverty level [FPL]; higher-income Medicaid [Right From the Start Medicaid in Georgia; family income ~50%-138% FPL]; and CHIP (called PeachCare in Georgia) [138%-247% FPL] and other (eg, foster care); (4) relationship of child to head of household (eg, child, grandchild); and (5) months of participation (1-3, 4-6, 7-9, and 10) in Medicaid/CHIP in school year. School-level variables²⁶ included (1) percentage of children eligible for free or reduced-price lunch at school, (2) student–teacher ratio, and (3) percentage of population living in poverty at the county level. We used Pearson χ² tests to compare sociodemographic characteristics and Medicaid program variables of SBHC and comparison students and t tests to compare school-level variables. We conducted multivariate analyses in 2017-2020 using Stata version 16.1 (StataCorp LLC) and robust SEs. Individual coefficients/marginal effects used the 2-tailed z test. P < .05 was considered significant.

Results

The sociodemographic characteristics of Medicaid/CHIP-enrolled children in the treatment and comparison school districts were generally similar in the pre-implementation and post-implementation periods (Table 2), although children in the treatment districts were older and less likely to be girls. Because children were in the study for some part of both the pre- and post-implementation periods, their average age increased from approximately 7½ to >9 years.

Table 2

Child characteristics in school districts^a with and without an SBHC,^b before and after implementation of SBHCs in schools in Georgia, in a study on the use of SBHCs among Medicaid/CHIP-enrolled children with asthma^c

Characteristics	Schools with an SBHC		P value^d	Schools without an SBHC		P value^d
Characteristics	Pre-implementation, 2011-2013	Post-implementation, 2013-2018	P value^d	Pre-implementation, 2011-2013	Post-implementation, 2013-2018	P value^d
No. of Medicaid/CHIP-insured school years^a	333	525	—^e	270	478	—^e
Sociodemographic
Age
Mean, y^f	7.7	9.7	<.001	7.4	9.5	<.001
Aged 5-7	47.4	12.4	<.001	54.8	16.3	<.001
Aged 8-12	52.6	87.6	<.001	45.2	83.7	<.001
Female	40.8	42.9	.56	45.2	46.0	.82
Race/ethnicity			.01			.06
Hispanic	32.7	27.6		30.0	26.4
Non-Hispanic Black	44.1	40.0		45.9	40.8
Non-Hispanic White	21.9	28.8		21.9	28.0
Non-Hispanic other^g	1.2	3.6		2.2	4.8
No. of months child in Medicaid/CHIP in school year			.94			.53
1-3	8.4	7.8		5.9	6.5
4-6	7.8	7.6		8.9	7.7
7-9	14.7	13.5		16.7	13.2
10	69.1	71.0		68.5	72.6
No. of years child in school district area during study			<.001			<.001
2	3.9	2.5		4.8	2.7
3	25.5	10.9		21.9	9.0
4	24.9	17.7		19.3	13.4
5	15.0	16.4		17.8	20.7
6	17.4	31.2		20.7	32.2
7	13.2	21.3		15.6	22.0
Medicaid program
Eligibility			.54			.71
PeachCare (CHIP)	14.7	11.8		14.1	15.7
Right From the Start Medicaid	60.1	61.9		57.0	57.7
Low-income Medicaid/other	22.5	22.5		24.8	23.8
Missing data	2.7	3.8		4.1	2.7
Relationship of child to head of household			.40			.78
Child	76.6	78.1		77.4	77.0
Unknown	18.6	18.9		17.0	18.8
Grandchild	3.9	2.9		3.3	2.7
Other^h	0.9	0.2		2.2	1.5
School level
Students who receive free or reduced-price lunch	90.8	90.4	.61	90.9	91.2	.64
Student–teacher ratio	16.1	14.9	<.001	14.3	14.7	.02
Families living in poverty in the county	25.4	23.0	<.001	24.2	21.4	<.001

Abbreviations: CHIP, Children’s Health Insurance Program; SBHC, school-based health center.

^aThe unit of observation was child–school year. Each child was in the study ≥2 years with a minimum of 1 school year in the pre-implementation period and 1 school year in the post-implementation period. There were 193 children in SBHC schools with a mean of 1.7 school years in the pre-implementation period and 2.7 school years in the post-implementation period. There were 163 children in comparison school districts with a mean of 1.7 school years in the pre-implementation period and 2.9 school years in the post-implementation period.

^bTreatment districts (school districts with an SBHC) and comparison districts (school districts without an SBHC) were defined by zip codes served by SBHCs in 3 counties. In Fulton County, treatment and comparison schools were urban/Hispanic; in Dougherty County, small city/non-Hispanic Black; in Catoosa County, rural/non-Hispanic White. Children ever in Medicaid/PeachCare (CHIP) and residing in the school district were considered exposed to the SBHC at the start of the school year, in August.

^cData source: Georgia Department of Community Health.²³ All values are percentages unless otherwise indicated (mean age and student–teacher ratio).

^dPearson χ² test used to compare sociodemographic characteristics and Medicaid program variables of SBHC and comparison students from pre-implementation to post-implementation. Student t test used to compare school-level variables; P < .05 considered significant.

^eNot applicable.

^fAge at beginning of school year of the school years August–May 2011-2012 through August–May 2017-2018. Increase in mean age indicates that the sample includes only children in the districts for some part of the pre-implementation and post-implementation periods.

^gIncludes Asian, Pacific Islander, Native American, or other.

^hIncludes nephew/niece, cousin, sibling, and stepdaughter/son.

More than 70% of both the treatment and comparison groups in the 2 school districts with predominantly racial/ethnic minority students (urban/Hispanic and small city/non-Hispanic Black) were either Hispanic or non-Hispanic Black in the pre-implementation period. More than 68% of children with asthma in both school districts were enrolled in Medicaid/CHIP for the full school year (10 months), and most had resided in their school district for >3 years. More than half (57.0%-61.9%) of children with asthma were eligible for the higher-income Right From the Start Medicaid; 22.5%-24.8% were eligible for low-income Medicaid.

We found a significant and larger increase in the receipt of well-child visits among children in a school district with an SBHC than in a district without an SBHC (Table 3). We found a decline in the receipt of influenza vaccinations in both groups from pre-implementation to post-implementation. We also found a significant decline in all-cause ED visits, asthma-related ED visits, and receipt of asthma management and asthma-relief and asthma-control medications in both districts from pre-implementation to post-implementation.

Table 3

Measures of health care use among Medicaid/CHIP-eligible children^a with asthma in elementary school districts with an SBHC versus elementary school districts without an SBHC^b and users versus nonusers of SBHCs before (years 2011-2013) and after (years 2013-2018) implementation of SBHCs in schools in Georgia^c

Measure	School districts with an SBHC					School districts without an SBHC
	Pre-implementation,2011-2013	Post-implementation,2013-2018	P value^d	Post-implementation		Pre-implementation,2011-2013	Post-implementation,2013-2018	P value^d
	Pre-implementation,2011-2013	Post-implementation,2013-2018	P value^d	User of SBHC	Nonuser of SBHC	Pre-implementation,2011-2013	Post-implementation,2013-2018	P value^d
No. of Medicaid/CHIP-insured school years^a	333	525	—^e	180	345	270	478	—^e
Well-child visit^f	44.1	51.0	.049	58.3	47.2	47.4	51.9	.24
Influenza vaccination^g	38.1	35.0	.36	45.0	29.9	45.9	28.7	<.001
All-cause emergency department use^h	36.9	28.6	.01	33.9	25.8	41.1	31.4	.007
Use of emergency department for asthma-related visitⁱ	12.6	7.6	.02	10.0	6.4	9.6	4.4	.005
≥3 Asthma outpatient visits	59.2	42.3	<.001	52.8	36.8	54.4	36.2	<.001
Use of asthma-relief medications^j	75.7	55.0	<.001	62.2	51.3	77.0	55.0	<.001
Use of asthma-control medications^k	61.9	51.0	.002	58.9	47.0	57.4	45.8	.002
Use of ≥2 asthma-control medications^l	53.5	42.3	.001	48.3	39.1	49.6	36.6	.001

Abbreviations: CHIP, Children’s Health Insurance Program; SBHC, school-based health center.

^aThe unit of observation was child–school year. Each child was in the study ≥2 years with a minimum of 1 school year in the pre-implementation period and 1 school year in the post-implementation period. There were 193 children in school districts that had an SBHC with a mean of 1.7 school years in the pre-implementation period and 2.7 years in the post-implementation period. There were 163 children in comparison school districts with a mean of 1.7 school years in the pre-implementation period and 2.9 years in the post-implementation period.

^bTreatment and comparison districts were defined by zip codes served by SBHCs in 3 counties. In Fulton County, treatment and comparison schools were urban/Hispanic; in Dougherty County, small city/non-Hispanic Black; in Catoosa County, rural/non-Hispanic White. Children ever in Medicaid/PeachCare (CHIP) and residing in the school district were considered exposed to the SBHC at the start of the school year, in August.

^cData source: Georgia Department of Community Health.²³

^dPearson χ² test used for Medicaid program variables (eg, eligibility categories); P < .05 considered significant.

^eNot applicable.

^fWell-child visit defined using Early and Periodic Screening, Diagnosis, and Treatment or International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)²⁷ code V202 or International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)²⁸ code Z0012X.

^gInfluenza vaccination defined using Current Procedural Terminology (CPT) codes 90630, 90653, 90654, 90656, 90657, 90658, 90660, 90661, 90662, 90664, 90666, 90667, 90668, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, and 90756; and Healthcare Common Procedural Coding System codes G0008, G9142, Q2034, Q2035, Q2036, Q2037, Q2038, and Q2039.

^hDefined by using place of service equal to emergency department (field 23).

ⁱDefined by using place of service equal to emergency department (field 23) with a primary diagnosis code of asthma (ICD-9-CM diagnosis code of 493 or ICD-10-CM diagnosis code of J45).

^jDefined as ≥3 outpatient claims with a primary or secondary asthma diagnosis (ICD-9-CM diagnosis code of 493 or ICD-10-CM diagnosis code of J45) on ≥3 dates during the school year.

^kDefined as ≥1 prescription fill during the school year for albuterol, levalbuterol, pirbuterol, Maxair, ProAir, Proventil, Ventolin, or Xopenex.

^lDefined as ≥1 prescription fill during the school year for beclomethasone, budesonide, budesonide-formoterol, ciclesonide, dyphylline, dyphylline-guaifenesin, flunisolide, fluticasone, fluticasone-salmeterol, fluticasone-vilanterol, formoterol-mometasone, guaifenesin-theophylline, mepolizumab, mometasone, montelukast, omalizumab, reslizumab, theophylline, Accolate, Advair, Aerospan, AirDuo, Alvesco, ArmonAir, Arnuity, Asmanex, Breo, Cinqair, Difil, Dulera, ED Bron, Elixophyllin, Flovent, Jay-Phyl, Lufyllin, montelukast, Nucala, Pulmicort, Qvar, Singulair, Symbicort, theo-24, Xolair, zafirlukast, zileuton, Zyflo, zafirlukast, or zileuton.

School attendance in an SBHC school district, however, did not mean that a child used the SBHC. Data on SBHC users and nonusers indicated that children with asthma who used services at their SBHC had higher rates of well-child visits, receipt of influenza vaccination, and asthma-related care, including use of asthma-relief and asthma-control medications; however, their use of the ED was also higher.

Multivariable Analysis

We found a higher probability of receipt of influenza vaccination of 26.3 percentage points (P = .048) among children in the treatment/urban/Hispanic school district compared with children in the comparison/urban/Hispanic school district, but we also found a higher probability of asthma-related ED visits (P = .05) among children in the treatment school district.

SBHC nonusers (n = 345 child–school years post-implementation) served as the control group for SBHC users (n = 180 child–school years post-implementation) (Table 4). We found significant differences between SBHC users and nonusers of 29.6 (P < .001) and 33.0 (P < .001) percentage points in well-child/EPSDT visits and receipt of influenza vaccinations, respectively, but only in the treatment/small city/non-Hispanic Black school district. We found positive and significant percentage-point differences in asthma-related ED visits (12.7; P =.04) and receipt of both asthma-relief (21.8; P < .001) and asthma-control medications (19.1; P = .01) between SBHC users and nonusers in treatment/urban/Hispanic school districts. We also found positive and significant percentage-point differences in receipt of both asthma-relief medications (23.7; P < .001) and asthma-control medications (28.7; P < .001) between SBHC users and nonusers in treatment/urban/non-Hispanic Black school districts. Among children who received asthma-control medications, we found significant percentage-point differences between users and nonusers in receipt of ≥2 medications in the treatment/small city/non-Hispanic Black school district (30.4; P < .001) and treatment/urban/Hispanic school district (15.4; P = .03). In all instances, the magnitude of the difference was largest for SBHC users in the treatment/small city/non-Hispanic Black school district. We found an 18.3 (P = .02) percentage-point difference in the probability of any ED visit and a 12.7 (P = .04) percentage-point difference in the probability of any asthma-related ED visit among SBHC users versus nonusers in the treatment/urban/Hispanic school district.

Table 4

Regression analysis of use of health care services among Medicaid/CHIP-enrolled children with asthma in elementary school districts with an SBHC (treatment) versus school districts without an SBHC (comparison), and users versus nonusers of SBHCs, before (years 2011-2013) and after (years 2013-2018) implementation of SBHCs in Georgia^a

Variable	No. of child–school years^b	Coefficient/marginal effect (P value)
Variable	No. of child–school years^b	Well-child/EPSDT visit	% With influenza vaccination	Regular management of asthma (≥3 visits per school year)^c	Asthma-control medication	Asthma-relief medication	≥2 Asthma-control medications	Any visit to emergency department	Any asthma-related visit to emergency department
Child with asthma in treatment district vs child with asthma in comparison district^d
Treatment vs comparison (both rural/non-Hispanic White)	241	−25.6 (.06)	−8.0 (.50)	−0.7 (.96)	−0.1 (>.99)	−1.8 (.90)	11.0 (.48)	5.0 (.70)	—^e
Treatment vs comparison (both small city/non-Hispanic Black)	698	6.5 (.68)	−5.4 (.72)	−11.3 (.47)	−0.6 (.97)	−6.2 (.67)	−6.3 (.68)	−13.4 (.36)	3.5 (.73)
Treatment vs comparison (both urban/Hispanic)	667	18.0 (.17)	26.3 (.048)	−0.87 (.96)	−10.7 (.46)	−1.5 (.91)	−17.3 (.25)	−1.2 (.93)	40.8 (.05)
All	1606	−2.2 (.73)	8.3 (.18)	0.2 (.97)	2.4 (.70)	−0.4 (.95)	1.0 (.87)	−2.6 (.64)	1.5 (.67)
Child with asthma using an SBHC in treatment district vs child with asthma not using an SBHC in treatment district^d
Treatment area/rural/non-Hispanic White	138	−9.8 (.42)	7.1 (.51)	−18.0 (.10)	−19.3 (.04)	−24.7 (.008)	−34.1 (.001)	10.2 (.35)	—^e
Treatment area/small city/non-Hispanic Black	416	29.6 (<.001)	33.0 (<.001)	33.4 (<.001)	28.7 (<.001)	23.7 (<.001)	30.4 (<.001)	−2.5 (.70)	—^e
Treatment area/urban/Hispanic	304	−7.9 (.32)	−0.5 (.95)	18.8 (.01)	19.1 (.01)	21.8 (.003)	15.4 (.03)	18.3 (.02)	12.7 (.04)
All	858	11.2 (.01)	15.9 (<.001)	17.4 (<.001)	14.0 (.002)	10.8 (.01)	11.6 (.01)	8.4 (.04)	3.7 (.17)

Abbreviations: CHIP, Children's Health Insurance Program; EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; SBHC, school-based health center.

^aData source: Georgia Department of Community Health.²³ Coefficients/marginal effects determined by 2-tailed z test, with P < .05 considered significant. Marginal effects adjusted for age, race/ethnicity, Medicaid eligibility category, relationship of child to head of household, number of months that child participated in study during school year, percentage of students receiving free or reduced-price lunch at school, student–teacher ratio, percentage of population living in poverty in county, school year, and school.

^bUnit of observation is child–school year, and each child must be in school district at least 1 year before implementation of the SBHCs (school years 2011-2012 and 2012-2013) and 1 year after implementation (2013-2014 through 2017-2018).

^cOutpatient visits with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 493 or 2 secondary diagnoses of ICD-9-CM code 493 ≥30 days apart²⁷; ICD-9-CM code 493 was used before October 1, 2015, and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code J45²⁸ was used after September 30, 2015.

^dIn Medicaid/CHIP and school district in the pre-implementation and post-implementation periods and diagnosed with asthma in the pre-implementation period.

^eNumber is too small for estimation of effect.

Children With Newly Diagnosed Asthma

Analyzing data from the post-implementation period only, we found a higher (4.7% vs 3.5%) percentage of newly diagnosed cases in the treatment school districts than in the comparison districts and a higher (62.4% vs 34.3%) rate of SBHC use among children with newly diagnosed asthma than among children diagnosed in the pre-implementation period. Children newly diagnosed with asthma in the treatment/small city/non-Hispanic Black district were more likely than children in the comparison/small city/non-Hispanic Black district to receive well-child visits and influenza vaccinations and have regular asthma management visits (all P < .01) (Table 5). In the small city/non-Hispanic Black area among children with newly diagnosed asthma, children in the treatment area had 23.4 percentage points fewer ED visits than children in the comparison area (P < .001).

Table 5

Regression analysis of use of health care services among Medicaid/CHIP-enrolled children with newly diagnosed asthma in elementary school districts with an SBHC (treatment) versus school districts without an SBHC (comparison), and users versus nonusers of SBHCs, before and after implementation of SBHCs in Georgia, 2011-2018^a

Variable	No. of child–school years^b	Coefficient/marginal effect (P value)
Variable	No. of child–school years^b	Well-child/EPSDT visit	% With influenza vaccination	Regular management of asthma (≥3 visits per school year)^c	Asthma-control medication	Asthma-relief medication	≥2 Asthma-control medications	Any visits to emergency department
Child with newly diagnosed asthma in treatment district vs comparison district^d
Treatment school vs comparison school (both rural/non-Hispanic White)	123	−77.3 (.70)	−169.0 (.43)	−229.3 (.24)	−56.2 (.72)	−55.4 (.73)	−148.0 (.41)	147.3 (.37)
Treatment school vs comparison school (both small city/non-Hispanic Black)	267	27.1 (<.001)	19.9 (.005)	17.9 (.008)	5.3 (.46)	11.1 (.11)	10.4 (.14)	−23.4 (<.001)
Treatment school vs comparison school (both urban/Hispanic)	312	−1.8 (.94)	−49.8 (.01)	−6.7 (.76)	−15.8 (.48)	21.2 (.39)	−20.1 (.31)	−23.2 (.30)
All	702	10.8 (.01)	7.6 (.05)	1.5 (.69)	−7.1 (.10)	6.0 (.16)	−3.7 (.36)	−1.6 (.71)
Child with newly diagnosed asthma in treatment district using an SBHC vs not using an SBHC^e
Treatment area/rural/non-Hispanic White	69	−13.1 (.36)	−9.9 (.48)	−7.2 (.56)	0.7 (.96)	−17.3 (.11)	−12.0 (.44)	44.2 (<.001)
Treatment area/small city/non-Hispanic Black	195	40.4 (<.001)	43.5 (<.001)	31.5 (<.001)	14.4 (.048)	17.7 (.009)	28.0 (<.001)	3.7 (.56)
Treatment area/urban/Hispanic	132	17.4 (.04)	3.2 (.73)	12.5 (.14)	11.9 (.15)	8.0 (.42)	9.0 (.19)	−5.6 (.54)
All	396	21.4 (<.001)	20.2 (<.001)	15.2 (.002)	5.3 (.29)	7.0 (.17)	10.8 (.02)	5.8 (.21)

Abbreviations: CHIP, Children’s Health Insurance Program; EPSDT, Early and Periodic Screening, Diagnosis, and Treatment; SBHC, school-based health center.

^aData source: Georgia Department of Community Health.²³ Coefficients/marginal effects determined by 2-tailed z test. Marginal effects adjusted for age, race/ethnicity, Medicaid eligibility category, relationship of child to head of household, number of months that child participated in study during school year, percentage of students receiving free or reduced-price lunch at school, student–teacher ratio, percentage of population living in poverty in county, school year, and school.

^bThe unit of observation is child–school year, and each child has to be in school district at least 1 year before implementation of the SBHCs (school years 2011-2012 and 2012-2013) and 1 year after implementation (2013-2014 through 2017-2018).

^dIn Medicaid/CHIP and school district in the pre-implementation and post-implementation periods and diagnosed with asthma only in the post-implementation period.

^eRestricted to children in school district with SBHCs. In Medicaid/CHIP and SBHC school district in the pre-implementation and post-implementation periods and diagnosed with asthma only in the post-implementation period.

In our assessment of the severity of asthma in the post-implementation period using ICD-10-CM codes, we found that 85.4% of all children with moderate or severe asthma received ≥1 asthma-control medication. Children with newly diagnosed asthma who used SBHCs in the treatment/small city/non-Hispanic Black and treatment/urban/Hispanic schools were more likely than nonusers to attend well-child visits (40.4 [P < .001] and 17.4 [P = .04] percentage-point differences, respectively), and in the treatment/small city/non-Hispanic Black school, SBHC users were more likely than nonusers to receive regular asthma management and asthma-relief and asthma-control medications.

Discussion

We found that children with previously diagnosed asthma aged 5-12 years with a new SBHC in their school district were more likely than children without an SBHC in their school district to have improved case management in 2 of 3 school districts studied here. However, improvement was significantly better only among children who used their SBHC and who lived in majority–racial/ethnic minority communities. Proportionately more children in schools with an SBHC were newly diagnosed with asthma after the SBHCs began operation. Newly diagnosed children with access to the urban/non-Hispanic Black school district SBHC were more likely than children without access to an SBHC to receive preventive services and adequate asthma management, and these effects were larger among SBHC users versus nonusers. These measures of adequacy address some, but not all, of the guidelines of the National Heart, Lung, and Blood Institute²¹ and National Asthma Education and Prevention Program.³¹

The Georgia Medicaid/CHIP program could save health care costs as SBHCs grow in number in CMO provider networks. However, CMO provider payments for SBHC users were slightly higher than for nonusers, reflecting higher outpatient and dental expenses but lower expenses for ED visits, inpatient hospitalizations, and medications. In the short run, our findings may reflect more efficient provision of services as SBHCs increase preventive care; however, we were unable to show reductions in ED use or hospitalizations that would indicate cost savings. Research on the effects of the expansion of SBHCs in Georgia on broader and longer-term measures of costs and outcomes (eg, school attendance) is needed.

Our study highlights the need to reduce access barriers to asthma diagnosis and clinical management. Racial/ethnic minority children and adolescents have been found to use SBHCs more frequently than other community delivery sites,^32,33 and use of SBHCs has been found to be greater in urban elementary schools than in rural elementary schools.³³ Consistent with other studies on the use of SBHCs,³³ we found that 34.3% of children with asthma used their SBHC. Of the 3 schools in our study with an SBHC, use of the SBHC by children with asthma was highest at the urban/Hispanic school (36.7%) and similar at the other 2 schools (32.8% and 33.3%); among children with newly diagnosed asthma, SBHC use was highest at the 2 majority–racial/ethnic minority SBHCs (60.6% and 65.6%). In a qualitative study of barriers and facilitators to SBHC use in the 3 pilot communities, investigators recommended more and better communication between SBHC staff members and parents, especially parents of children who had not used the SBHC.³⁴ The higher rate of ED use in the urban/Hispanic school may reflect the need for these families to access care after SBHC hours. Language barriers and high turnover among staff members at this SBHC also posed a challenge.³⁴ Other trends or findings in this study underscore the importance of recognizing cultural differences across areas (rural vs urban) and parent groups (non-Hispanic White vs non-Hispanic Black vs Hispanic) to increase community buy-in and use of SBHCs.

The decline in receipt of influenza vaccinations from pre-implementation to post-implementation seen in the descriptive data may reflect shifts in parents’ attitudes toward and suspicions about vaccinations, a trend observed by health care providers serving low-income and racial/ethnic minority families.³⁵ Our finding that SBHCs moderated this downward trend, especially in predominantly racial/ethnic minority SBHCs, is important.

Limitations

Our study had 2 limitations. First, children identified as living in the SBHC school district may not attend the public school but may be homeschooled or attend private schools. However, charter schools represent fewer than 5% of Georgia’s schools, and children from low-income families are less likely than children from high-income families to attend them.³⁶ Second, we could not measure the effects of the SBHCs on uninsured or undocumented children. Thus, our results may not be generalizable beyond the 3 communities studied.

Conclusion

To our knowledge, our study is the first to measure the adequacy of health care among children with asthma who attend public elementary schools and are enrolled in Medicaid/CHIP. The more than doubling of SBHCs in the United States from 1135 in 1999 to 2584 in 2017 reflects their importance as a medical home for low-income and racial/ethnic minority children with ongoing health needs such as asthma.³⁷ Improved case management of children using an SBHC is an encouraging indication that the increasing number of elementary SBHCs will continue to improve the health of young children living with asthma. Thus, we confirm the role of SBHCs in increasing access to health care services among elementary school–aged children³⁸ and their potential to reduce racial/ethnic disparities in service receipt.^25,38

-42

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received financial support for creating the database and conducting initial analyses from National Institute on Minority Health and Health Disparities grant number 5R01MD008966-02, Effect of School-Based Health Centers on Reducing Students Health Disparities. However, research, authorship, and/or publication of this article was conducted without further funds.

ORCID iD

E. Kathleen Adams, PhD

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