1. Department of Family and Community Medicine Measuring up to the common core: What is known about the delivery of primary care in school-based health centers (SBHCs) April 27, 2015 Elizabeth Uy-Smith 1 MD MPH MAS Kevin Grumbach 1 MD Claire D. Brindis 7 DrPH 1 UCSF Department of Family and Community Medicine 2 UCSF Philip R. Lee Institute for Health Policy Studies, Department of Pediatrics, Division of Adolescent Medicine, UCSF Benioff Children’s Hospital

2. Department of Family and Community Medicine No relationships to disclose. Presenter Disclosures

3. Department of Family and Community Medicine Background: School-Based Health Centers School-Based Health Center (SBHC) = health centers that deliver comprehensive primary care to adolescents within a school setting Approximately 2000 SBHCs nationwide Received $200 million in the Affordable Care Act (ACA) Limited research has assessed the ability of SBHCs to deliver primary care

4. Department of Family and Community Medicine Study Objective To evaluate the evidence for SBHC delivery of the four core characteristics of primary care 1 – access, continuity, comprehensiveness, and coordination – through a comprehensive literature review. 1 Starfield B. Primary care: concept, evaluation, and policy. New York, NY; 1992.

5. Department of Family and Community Medicine Methods: Literature Search Searched MEDLINE, Cochrane Central and reference lists from January 1970 to April 2014 for articles related to primary care health services delivered within an on-site school-based health center. ‒Search terms: “School Health Services”[MeSH] OR school* clinic” AND (“Primary Health Care”[MeSH] OR “Comprehensive Health Care”[MeSH])

6. Department of Family and Community Medicine Methods: Quality Assessment Standardized abstraction form with grading criteria from the U.S. Task Force on Community Preventive Services (USPSTF) USPSTF Grade based on study design: –Level I: randomized controlled trial –Level II-1:well-designed controlled trial without randomization –Level II-2: well-designed cohort or case-control analytic study –Level II-3: multiple time series with or without the intervention –Level III: expert opinions, descriptive studies or case reports Quality based on number of study limitations: –Good: 0-1 limitations –Fair: 2-4 limitations –Limited: 5 or more limitations

7. Department of Family and Community Medicine Results: Flow diagram of the selection of studies MEDLINE, Cochrane Central Database, and Reference Lists Search for Title and Abstract Review (n=301) Articles excluded based on title and abstract (n=286) Full-text articles assessed for eligibility (n=15) Full-text articles excluded, with reasons: No primary care outcomes (n=3) Elementary schools (n=2) Did not provide comprehensive health services (n=1) Studies included in final qualitative synthesis (n=9)

8. Department of Family and Community Medicine Results: Included Studies Eight of the nine studies included > 2 of the primary care core characteristics in the study. Primary Care Core Characteristic Number of Studies Access7 Continuity6 Comprehensiveness5 Coordination0

9. Department of Family and Community Medicine Results: Studies reporting on ACCESS in SBHCs Author, YearStudy siteStudy designGrade (USPSTF), quality Blum et al., 1982MinnesotaDescriptiveLevel III, Fair Anglin et al., 1996ColoradoCohortLevel II-2, Fair Kisker and Brown, 1996United States (nationwide) CohortLevel II-2, Fair Santelli et al., 1996MarylandCohortLevel II-2, Good Denny et al., 2005New ZealandCohortLevel II-2, Good Allison et al., 2007ColoradoCohortLevel II-2, Good Gibson et al., 2013New YorkCohortLevel II-2, Good

10. Department of Family and Community Medicine Results: Studies reporting on CONTINUITY in SBHCs Author, YearStudy siteStudy designGrade (USPSTF), quality Blum et al., 1982MinnesotaDescriptiveLevel III, Fair Meeker et al., 1986Colorado, New York, North Dakota, Utah DescriptiveLevel III, Fair Anglin et al., 1996ColoradoCohortLevel II-2, Fair Kisker and Brown, 1996United States (nationwide) CohortLevel II-2, Fair Allison et al., 2007ColoradoCohortLevel II-2, Good Gibson et al., 2013New YorkCohortLevel II-2, Good

11. Department of Family and Community Medicine Results: Studies reporting on COMPREHENSIVENESS in SBHCs Author, YearStudy siteStudy designGrade (USPSTF), quality Meeker et al., 1986Colorado, New York, North Dakota, Utah DescriptiveLevel III, Fair Anglin et al., 1996ColoradoCohortLevel II-2, Fair Santelli et al., 1996MarylandCohortLevel II-2, Good Kaplan et al., 1998ColoradoCohortLevel II-2, Good Denny et al., 2005New ZealandCohortLevel II-2, Good

12. Department of Family and Community Medicine Conclusions Overall, few good quality studies have investigated SBHC performance in delivering primary care. No studies on coordination of care in SBHCs. Good quality evidence suggests that adolescents receiving care from SBHCs receive comprehensive and continuous care. Less consistent evidence exists that SBHC users experience increased access to care, especially primary care services, compared to non-SBHC users.

13. Department of Family and Community Medicine Limitations Heterogeneity in the outcome measures prevented a formal synthesis of results. Publication bias for studies with statistically significant differences. Outdated studies, with majority of studies occurring prior to 1998.

14. Department of Family and Community Medicine Implications Insufficient evidence exists to determine SBHC ability to deliver primary care that is accessible, continuous, comprehensive, and coordinated for adolescents. Higher grade studies, especially exploring access and coordination of care, are needed to examine the potential of SBHCs for improving primary care delivery. Family physicians in non-traditional clinic settings, like SBHCs, must demonstrate the ability to deliver the core tenants of primary care.

15. Department of Family and Community Medicine Mentors: Peter Bacchetti, PhD Claire D. Brindis, DrPH Susan Egerter, PhD Kevin Grumbach, MD Margaret Handley, PhD MPH UCSF Primary Care Research Fellowship, NRSA T32HP19025 Acknowledgements Acknowledgments

16. Department of Family and Community Medicine