Opinion Editorial
ARTICLE INFORMATION Author Affiliation: Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada. Corresponding Author: Mark Asbridge, PhD, Department of Community Health and Epidemiology, Dalhousie University, 5790 University Ave, Fourth Floor, Halifax, Nova Scotia, B3H 1V7, Canada ([email protected]). Published Online: May 12, 2014. doi:10.1001/jamapediatrics.2014.83. Conflict of Interest Disclosures: None reported. REFERENCES 1. Whitehill JM, Rivara FP, Moreno MA. Marijuana-using drivers, alcohol-using drivers, and their passengers: prevalence and risk factors among underage college students [published online May 12, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.5300. 2. O’Malley PM, Johnston LD. Driving after drug or alcohol use by US high school seniors, 2001-2011. Am J Public Health. 2013;103(11):2027-2034. 3. Mura P, Chatelain C, Dumestre V, et al. Use of drugs of abuse in less than 30-year-old drivers killed in a road crash in France: a spectacular
increase for cannabis, cocaine and amphetamines. Forensic Sci Int. 2006;160(2-3):168-172.
Australia: NHMRC Road Accident Research Unit; 1995:295-300.
4. Asbridge M, Poulin C, Donato A. Motor vehicle collision risk and driving under the influence of cannabis: evidence from adolescents in Atlantic Canada. Accid Anal Prev. 2005;37(6):1025-1034.
10. Romano E, Pollini RA. Patterns of drug use in fatal crashes. Addiction. 2013;108(8):1428-1438.
5. Fergusson DM, Horwood LJ, Boden JM. Is driving under the influence of cannabis becoming a greater risk to driver safety than drink driving? findings from a longitudinal study. Accid Anal Prev. 2008;40(4):1345-1350. 6. Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet. 2009;374 (9698):1383-1391. 7. Bates MN, Blakely TA. Role of cannabis in motor vehicle crashes. Epidemiol Rev. 1999;21(2):222-232. 8. Ramaekers JG, Berghaus G, van Laar M, Drummer OH. Dose related risk of motor vehicle crashes after cannabis use. Drug Alcohol Depend. 2004;73(2):109-119. 9. Berghaus G, Guo BL. Medicines and driver fitness: findings from a meta-analysis of experimental studies as basic information to patients, physicians, and experts. In: Koedan CN, McLean AJ, eds. Proceedings of the 13th International Conference on Alcohol, Drugs, and Traffic Safety, August 13-18, 1995. Adelaide,
11. Laumon B, Gadegbeku B, Martin JL, Biecheler MB; SAM Group. Cannabis intoxication and fatal road crashes in France: population based case-control study. BMJ. 2005;331(7529):1371-1377. 12. Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana use and motor vehicle crashes. Epidemiol Rev. 2012;34(1):65-72. 13. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. 2012;344:e536. 14. Longo MC, Hunter CE, Lokan RJ, White JM, White MA. The prevalence of alcohol, cannabinoids, benzodiazepines and stimulants amongst injured drivers and their role in driver culpability, II: the relationship between drug prevalence and drug concentration, and driver culpability. Accid Anal Prev. 2000;32(5):623-632. 15. Grotenhermen F, Leson G, Berghaus G, et al. Developing limits for driving under cannabis. Addiction. 2007;102(12):1910-1917.
School Nursing Beyond Medications and Procedures Howard L. Taras, MD
Children spend 6 to 7 hours per day, 180 days per year in school in the United States. While education is the chief purpose, consideration for children’s health is a significant role of schools. Like math and reading, students need to be taught how Related article page 642 to have an optimally healthy life. We want each student to return home at the end of the day at least as healthy as when he or she arrived. School-age children, especially adolescents, young students, and those developmentally immature, are more apt than are adults to share pathogens through close contact and shared body fluids. Children with special health care needs are integrated into regular school and classroom settings where medications and medical procedures are delivered. Numerous health conditions manifest first as behavioral and educational problems. Many students have suboptimal access to primary and secondary health care, making schools the first place where their underlying physical and mental illnesses become apparent. The staffing of school health-related services is the subject of a study by Wang and colleagues1 in this issue of JAMA Pediatrics. In any economic evaluation of health interventions or resources, the specific outcomes that are measured are critical.2 The effects of improved school attendance on parents’ and schools’ budgets were measured in this article. Ad604
ditional beneficial outcomes of school nursing services need to be assessed. These plausibly include the cost-benefit of higher graduation rates, improved grades and standardized test scores, reduced use of community emergency services, better compliance with prescribed medical management, reduced transmission of infectious diseases, and earlier diagnoses and treatment. The authors recognize that they omitted school nursing roles that require the most training and creativity. These omitted roles may turn out to be the most costbeneficial to society. Great variation exists among and within states for how school districts staff their health-related services. In some counties, school health staffing and resources are responsibilities of public health departments. In most locales, school health programs are organized entirely from within the educational sector, where they compete for the same dollars that can be used for instruction and educational infrastructure. During the past decade and longer, fluctuations in school budgets have necessitated that districts modify their models of health service provision, a circumstance that is disruptive to health program planning. For example, many schools that once may have been staffed by full-time, certified, registered school nurses may now be staffed by unlicensed assistive personnel (UAP) operating under the indirect supervision of a nurse. If
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Copyright 2014 American Medical Association. All rights reserved.
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Editorial Opinion
there is any good news from this, it is that school health is a field that is naturally prepared for comparative research. Wang et al1 address the administration of medications, the triage of symptomatic students, and school-based health screens as the tasks of school nurses to determine the costbenefit of school nursing. Having a registered school nurse administer medications, perform medical procedures, and conduct health screens in school was compared with a scenario where no one performs these functions in school. However, even though in some states, school nurses are prohibited from delegation, in thousands of schools across the United States, these tasks are effectively covered by licensed vocational nurses, licensed practical nurses, or UAP.3 The strength of the cost analysis by Wang et al1 is that they compared school nurses with UAP for the tasks of dismissing students early from school for injury or illness. They also estimated differences in costs for schools with and without a school nurse, based on how much time teachers spent on health issues. A weakness in this cost analysis is the assumption that without a school nurse, medications would not be administered and procedures would not be performed. The authors describe this comparative scenario as “hypothetical” because, in fact, schools without a registered school nurse are mandated by law to have other personnel provide these services. Caution must be taken with cost analyses of hypothetical situations. An analogous situation would be to assume that if no plastic surgeon were available in an emergency department to suture lacerations, then patients would go home unsutured. For emergency department lacerations, as for school-age students requiring medications and procedures, many other professionals with less training can and do perform these functions adeptly. It is unfortunate when educators, health professionals, public health officials, and parents regard school nurses’ ability to safely administer medications and provide healthrelated procedures as this profession’s unique value to schools. On occasion, some nursing organizations have argued that the administration of medications (eg, oral and inhaled medications, insulin, and rectal diazepam) should be performed solely by school nurses, not other personnel, and that only school nurses can truly assess when a student is qualified to receive an “as-needed” medication.4,5 These arguments are not disingenuous. Yet, many school nurses who train unlicensed school staff can attest to the reliability of trained UAP to correctly identify a seizure, recognize respiratory distress, interpret high glucometer and peak flow meter readings, and distinguish between distressed-looking students with headaches and those who claim to have headaches but skip merrily into the health office conveniently during a math test. Although they administer medications and conduct health care procedures, UAP, licensed vocational nurses, and licensed practical nurses cannot reliably assume numerous im-
ARTICLE INFORMATION Author Affiliation: Clinical and Translational Research Institute, Department of Pediatrics, University of California, San Diego. Corresponding Author: Howard L. Taras, MD, Clinical and Translational Research Institute, jamapediatrics.com
portant functions in the field of school health. By virtue of their training in the medical and educational sectors, school nurses are the best bridges between these sectors. With their feet in both worlds, school nurses understand the occupational culture and jargon of educators as well as the culture and language of the health sector.6 This places school nurses in a unique position as interpreters between two occupational cultures, an important function for nurses who operate as child advocates and as parent advisers. School nurses regularly educate other members of school staff on diseases affecting students’ school functioning and safety: eating disorders, mental and emotional problems, asthma, type 1 and type 2 diabetes mellitus, epilepsy, tic disorders, encopresis, food intolerances, allergies, irritable bowel syndrome, myopia, and just about any condition that perplexes non–health professionals confronted with a student who demonstrates the signs and symptoms of these maladies.7-10 Similarly, school nurses, unlike licensed vocational nurses, licensed practical nurses, or school administrators, are comfortable communicating with students’ physicians to better understand a medical condition and its management and prognosis. School nurses explain to physicians the vast range of resources and accommodations that schools can offer, as well as those educational laws that protect students’ health rights in school. School nurses are in the best position to assess children with special health care needs and plan for their safe integration into the school setting. They investigate health factors that underlie recurrent absenteeism, contribute to educational underachievement, and manifest as social or behavior problems in the school setting.11,12 Few, if any, other professions can provide both educational and health case management. School nurses, more than any other professional in the school setting, are adept at conducting one-on-one counseling and handling school policies related to student sexuality (eg, puberty, sexual identity, safe sexual practices, and pregnancy).13,14 Through their associations with their professional organizations and their own journals, school nurses are ideally poised to evaluate whether and how to implement schoolwide programs, such as automated external defibrillator placement, health screening, immunization clinics, or emergency health planning for disasters.15 In summary, the true cost-benefit of school nurses are their analytical brains, not their brawn, for procedures. Some sparse published literature on the economics of school health exists for schools in the United States, United Kingdom, and Canada.16-19 School health is a field that still begs the input of health economists. Nursing and other professional organizations publish guidelines describing the role of a school nurse and recommend student-to-nurse ratios,20 but these ratios lack a solid evidence base. Wang et al1 reopen this vital discussion and leave room for much more.
Department of Pediatrics, University of California, San Diego, 9500 Gilman Dr, Ste 0990, La Jolla, CA 92093-0990 ([email protected]). Published Online: May 19, 2014. doi:10.1001/jamapediatrics.2014.451.
Conflict of Interest Disclosures: Dr Taras reported being the district physician for the San Diego Unified School District and consultant for numerous school districts throughout California. He reported being a past chairperson for the Council on School Health of the American Academy of Pediatrics.
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Copyright 2014 American Medical Association. All rights reserved.
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Opinion Editorial
REFERENCES 1. Wang LY, Vernon-Smiley M, Gapinski MA, Desisto M, Maughan E, Sheetz A. Cost-benefit study of school nursing services [published online May 19, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.5441. 2. Johannesson M, Jönsson B, Karlsson G. Outcome measurement in economic evaluation. Health Econ. 1996;5(4):279-296. 3. Shannon RA, Kubelka S. Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, part 2. NASN Sch Nurse. 2013;28(5):222-226. 4. O’Dell C, O’Hara K. School nurses’ experience with administration of rectal diazepam gel for seizures. J Sch Nurs. 2007;23(3):166-169. 5. Supreme Court of California. American Nurses Association v Tom Torlakson (Superintendent), American Diabetes Association (S184583), Sacramento, CA. August 12, 2013. http://www.cde.ca.gov/ls/he/hn/documents /anavtorlakson2013.pdf. Accessed February 25, 2014. 6. Maughan E, Adams R. Educators’ and parents’ perception of what school nurses do: the influence of school nurse/student ratios. J Sch Nurs. 2011;27 (5):355-363. 7. Funari M. Detecting symptoms, early intervention, and preventative education: eating
disorders & the school-age child. NASN Sch Nurse. 2013;28(3):162-166. 8. Schoessler S, White MV. Recognition and treatment of anaphylaxis in the school setting: the essential role of the school nurse. J Sch Nurs. 2013; 29(6):407-415. 9. Zacharski S, DeSisto M, Pontius D, Sheets J, Richesin C. For your information: management in the school setting: position statement. NASN Sch Nurse. 2013;28(5):263-265. 10. Pryjmachuk S, Graham T, Haddad M, Tylee A. School nurses’ perspectives on managing mental health problems in children and young people. J Clin Nurs. 2012;21(5-6):850-859. 11. Ramos MM, Greenberg C, Sapien R, Bauer-Creegan J, Hine B, Geary C. Behavioral health emergencies managed by school nurses working with adolescents. J Sch Health. 2013;83(10):712-717. 12. Rodriguez E, Rivera DA, Perlroth D, Becker E, Wang NE, Landau M. School nurses’ role in asthma management, school absenteeism, and cost savings: a demonstration project. J Sch Health. 2013;83(12):842-850.
orientation and gender identity/expression (sexual minority students): school nurse practice. NASN Sch Nurse. 2013;28(2):112-113. 15. Boudreaux S, Broussard L. Sudden cardiac arrest in schools: the role of the school nurse in AED program implementation. Issues Compr Pediatr Nurs. 2012;35(3-4):143-152. 16. Gleeson C. School nurses’ workloads: how should they be prioritised? Community Pract. 2009; 82(1):23-26. 17. Chabot G, Gagnon MP, Godin G. Redefining the school nurse role: an organizational perspective. J Health Organ Manag. 2012;26(4-5):444-466. 18. Guttu M, Engelke MK, Swanson M. Does the school nurse-to-student ratio make a difference? J Sch Health. 2004;74(1):6-9. 19. Cotton L, Brazier J, Hall DMB, et al. School nursing: costs and potential benefits. J Adv Nurs. 2000;31(5):1063-1071. 20. Durant BV, Gibbons LJ, Poole C, Suessmanm M, Wyckoff L. NASN position statement: caseload assignments. NASN Sch Nurse. 2011;26(1):49-51.
13. Brewin D, Koren A, Morgan B, Shipley S, Hardy RL. Behind closed doors: school nurses and sexual education. J Sch Nurs. 2014;30(1):31-41. 14. Bradley B, Kelts S, Robarge D, Davis C, Delger S, Compton L. NASN position statement: sexual
The Downside of Increased Cost Sharing Aaron E. Carroll, MD, MS
From 1971 through 1982, the RAND Corporation conducted the most comprehensive randomized clinical trial of health insurance ever performed.1 The investigators randomized more than 2700 families and 7700 individuals to 1 of 5 health insurRelated article page 649 ance plans with different levels of cost sharing. The major finding of the study was that increased cost sharing, or making people pay more out-ofpocket for their care, led people to spend less on health care. They also found that increased cost sharing did not, in general, lead to worse health outcomes.1 Since publication of the RAND Health Insurance Experiment findings, reduced health care spending as a result of increased cost sharing has become an accepted fact. Namely, people are more reluctant to spend their own money than someone else’s. However, one of the major limitations of the RAND study was that it contained mostly healthy people. Some investigators argue that the sickest people dropped out of the experiment voluntarily, thus skewing the population.2 Furthermore, healthy people almost by definition are going to be fine in the short term with less health care. Finding ways to get them to spend less is a good thing. What about people who are unhealthy? A less reported, but still important, finding of the RAND study was that poorer people with hypertension had significantly increased mortality. They likely avoided necessary care, which led to worse health outcomes.3 Cost sharing has very 606
different implications for people with chronic conditions. They need care, and if we incentivize them to avoid it, then outcomes can get worse. Cost sharing is the subject of a study by Fung et al,4 who conducted a telephone survey of 769 parents of children with asthma who were aged 4 to 11 years. They asked the parents about how they sought care for their child’s condition. Specifically, they gathered data on how financial stress and costs changed how they sought care. Their findings are not surprising, given our prior knowledge about cost sharing. Families with higher levels of cost sharing were more likely to avoid or delay office and emergency department visits. They were more likely to forgo care. They were also more likely to borrow money or cut back on necessities to afford the care they could give to their children. This finding should give all of us pause. These are children with asthma. The care they are avoiding, delaying, or forgoing is necessary care. We all know that when it comes to asthma, preventing exacerbations is better than treating them. Most surprising was who was most affected by cost sharing. The literature is replete with studies that show that Medicaid is associated with worse outcomes than private insurance. 5 In this case, however, Medicaid was not the underperformer. For the most part, Medicaid and the State Children’s Health Insurance Program have little, if any, cost sharing, which removes the financial burden for people to obtain care. Com-
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ARTICLE INFORMATION Author Affiliation: Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada. Corresponding Author: Mark Asbridge, PhD, Department of Community Health and Epidemiology, Dalhousie University, 5790 University Ave, Fourth Floor, Halifax, Nova Scotia, B3H 1V7, Canada ([email protected]). Published Online: May 12, 2014. doi:10.1001/jamapediatrics.2014.83. Conflict of Interest Disclosures: None reported. REFERENCES 1. Whitehill JM, Rivara FP, Moreno MA. Marijuana-using drivers, alcohol-using drivers, and their passengers: prevalence and risk factors among underage college students [published online May 12, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.5300. 2. O’Malley PM, Johnston LD. Driving after drug or alcohol use by US high school seniors, 2001-2011. Am J Public Health. 2013;103(11):2027-2034. 3. Mura P, Chatelain C, Dumestre V, et al. Use of drugs of abuse in less than 30-year-old drivers killed in a road crash in France: a spectacular
increase for cannabis, cocaine and amphetamines. Forensic Sci Int. 2006;160(2-3):168-172.
Australia: NHMRC Road Accident Research Unit; 1995:295-300.
4. Asbridge M, Poulin C, Donato A. Motor vehicle collision risk and driving under the influence of cannabis: evidence from adolescents in Atlantic Canada. Accid Anal Prev. 2005;37(6):1025-1034.
10. Romano E, Pollini RA. Patterns of drug use in fatal crashes. Addiction. 2013;108(8):1428-1438.
5. Fergusson DM, Horwood LJ, Boden JM. Is driving under the influence of cannabis becoming a greater risk to driver safety than drink driving? findings from a longitudinal study. Accid Anal Prev. 2008;40(4):1345-1350. 6. Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet. 2009;374 (9698):1383-1391. 7. Bates MN, Blakely TA. Role of cannabis in motor vehicle crashes. Epidemiol Rev. 1999;21(2):222-232. 8. Ramaekers JG, Berghaus G, van Laar M, Drummer OH. Dose related risk of motor vehicle crashes after cannabis use. Drug Alcohol Depend. 2004;73(2):109-119. 9. Berghaus G, Guo BL. Medicines and driver fitness: findings from a meta-analysis of experimental studies as basic information to patients, physicians, and experts. In: Koedan CN, McLean AJ, eds. Proceedings of the 13th International Conference on Alcohol, Drugs, and Traffic Safety, August 13-18, 1995. Adelaide,
11. Laumon B, Gadegbeku B, Martin JL, Biecheler MB; SAM Group. Cannabis intoxication and fatal road crashes in France: population based case-control study. BMJ. 2005;331(7529):1371-1377. 12. Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana use and motor vehicle crashes. Epidemiol Rev. 2012;34(1):65-72. 13. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. 2012;344:e536. 14. Longo MC, Hunter CE, Lokan RJ, White JM, White MA. The prevalence of alcohol, cannabinoids, benzodiazepines and stimulants amongst injured drivers and their role in driver culpability, II: the relationship between drug prevalence and drug concentration, and driver culpability. Accid Anal Prev. 2000;32(5):623-632. 15. Grotenhermen F, Leson G, Berghaus G, et al. Developing limits for driving under cannabis. Addiction. 2007;102(12):1910-1917.
School Nursing Beyond Medications and Procedures Howard L. Taras, MD
Children spend 6 to 7 hours per day, 180 days per year in school in the United States. While education is the chief purpose, consideration for children’s health is a significant role of schools. Like math and reading, students need to be taught how Related article page 642 to have an optimally healthy life. We want each student to return home at the end of the day at least as healthy as when he or she arrived. School-age children, especially adolescents, young students, and those developmentally immature, are more apt than are adults to share pathogens through close contact and shared body fluids. Children with special health care needs are integrated into regular school and classroom settings where medications and medical procedures are delivered. Numerous health conditions manifest first as behavioral and educational problems. Many students have suboptimal access to primary and secondary health care, making schools the first place where their underlying physical and mental illnesses become apparent. The staffing of school health-related services is the subject of a study by Wang and colleagues1 in this issue of JAMA Pediatrics. In any economic evaluation of health interventions or resources, the specific outcomes that are measured are critical.2 The effects of improved school attendance on parents’ and schools’ budgets were measured in this article. Ad604
ditional beneficial outcomes of school nursing services need to be assessed. These plausibly include the cost-benefit of higher graduation rates, improved grades and standardized test scores, reduced use of community emergency services, better compliance with prescribed medical management, reduced transmission of infectious diseases, and earlier diagnoses and treatment. The authors recognize that they omitted school nursing roles that require the most training and creativity. These omitted roles may turn out to be the most costbeneficial to society. Great variation exists among and within states for how school districts staff their health-related services. In some counties, school health staffing and resources are responsibilities of public health departments. In most locales, school health programs are organized entirely from within the educational sector, where they compete for the same dollars that can be used for instruction and educational infrastructure. During the past decade and longer, fluctuations in school budgets have necessitated that districts modify their models of health service provision, a circumstance that is disruptive to health program planning. For example, many schools that once may have been staffed by full-time, certified, registered school nurses may now be staffed by unlicensed assistive personnel (UAP) operating under the indirect supervision of a nurse. If
JAMA Pediatrics July 2014 Volume 168, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Nanyang Technological University User on 06/08/2015
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Editorial Opinion
there is any good news from this, it is that school health is a field that is naturally prepared for comparative research. Wang et al1 address the administration of medications, the triage of symptomatic students, and school-based health screens as the tasks of school nurses to determine the costbenefit of school nursing. Having a registered school nurse administer medications, perform medical procedures, and conduct health screens in school was compared with a scenario where no one performs these functions in school. However, even though in some states, school nurses are prohibited from delegation, in thousands of schools across the United States, these tasks are effectively covered by licensed vocational nurses, licensed practical nurses, or UAP.3 The strength of the cost analysis by Wang et al1 is that they compared school nurses with UAP for the tasks of dismissing students early from school for injury or illness. They also estimated differences in costs for schools with and without a school nurse, based on how much time teachers spent on health issues. A weakness in this cost analysis is the assumption that without a school nurse, medications would not be administered and procedures would not be performed. The authors describe this comparative scenario as “hypothetical” because, in fact, schools without a registered school nurse are mandated by law to have other personnel provide these services. Caution must be taken with cost analyses of hypothetical situations. An analogous situation would be to assume that if no plastic surgeon were available in an emergency department to suture lacerations, then patients would go home unsutured. For emergency department lacerations, as for school-age students requiring medications and procedures, many other professionals with less training can and do perform these functions adeptly. It is unfortunate when educators, health professionals, public health officials, and parents regard school nurses’ ability to safely administer medications and provide healthrelated procedures as this profession’s unique value to schools. On occasion, some nursing organizations have argued that the administration of medications (eg, oral and inhaled medications, insulin, and rectal diazepam) should be performed solely by school nurses, not other personnel, and that only school nurses can truly assess when a student is qualified to receive an “as-needed” medication.4,5 These arguments are not disingenuous. Yet, many school nurses who train unlicensed school staff can attest to the reliability of trained UAP to correctly identify a seizure, recognize respiratory distress, interpret high glucometer and peak flow meter readings, and distinguish between distressed-looking students with headaches and those who claim to have headaches but skip merrily into the health office conveniently during a math test. Although they administer medications and conduct health care procedures, UAP, licensed vocational nurses, and licensed practical nurses cannot reliably assume numerous im-
ARTICLE INFORMATION Author Affiliation: Clinical and Translational Research Institute, Department of Pediatrics, University of California, San Diego. Corresponding Author: Howard L. Taras, MD, Clinical and Translational Research Institute, jamapediatrics.com
portant functions in the field of school health. By virtue of their training in the medical and educational sectors, school nurses are the best bridges between these sectors. With their feet in both worlds, school nurses understand the occupational culture and jargon of educators as well as the culture and language of the health sector.6 This places school nurses in a unique position as interpreters between two occupational cultures, an important function for nurses who operate as child advocates and as parent advisers. School nurses regularly educate other members of school staff on diseases affecting students’ school functioning and safety: eating disorders, mental and emotional problems, asthma, type 1 and type 2 diabetes mellitus, epilepsy, tic disorders, encopresis, food intolerances, allergies, irritable bowel syndrome, myopia, and just about any condition that perplexes non–health professionals confronted with a student who demonstrates the signs and symptoms of these maladies.7-10 Similarly, school nurses, unlike licensed vocational nurses, licensed practical nurses, or school administrators, are comfortable communicating with students’ physicians to better understand a medical condition and its management and prognosis. School nurses explain to physicians the vast range of resources and accommodations that schools can offer, as well as those educational laws that protect students’ health rights in school. School nurses are in the best position to assess children with special health care needs and plan for their safe integration into the school setting. They investigate health factors that underlie recurrent absenteeism, contribute to educational underachievement, and manifest as social or behavior problems in the school setting.11,12 Few, if any, other professions can provide both educational and health case management. School nurses, more than any other professional in the school setting, are adept at conducting one-on-one counseling and handling school policies related to student sexuality (eg, puberty, sexual identity, safe sexual practices, and pregnancy).13,14 Through their associations with their professional organizations and their own journals, school nurses are ideally poised to evaluate whether and how to implement schoolwide programs, such as automated external defibrillator placement, health screening, immunization clinics, or emergency health planning for disasters.15 In summary, the true cost-benefit of school nurses are their analytical brains, not their brawn, for procedures. Some sparse published literature on the economics of school health exists for schools in the United States, United Kingdom, and Canada.16-19 School health is a field that still begs the input of health economists. Nursing and other professional organizations publish guidelines describing the role of a school nurse and recommend student-to-nurse ratios,20 but these ratios lack a solid evidence base. Wang et al1 reopen this vital discussion and leave room for much more.
Department of Pediatrics, University of California, San Diego, 9500 Gilman Dr, Ste 0990, La Jolla, CA 92093-0990 ([email protected]). Published Online: May 19, 2014. doi:10.1001/jamapediatrics.2014.451.
Conflict of Interest Disclosures: Dr Taras reported being the district physician for the San Diego Unified School District and consultant for numerous school districts throughout California. He reported being a past chairperson for the Council on School Health of the American Academy of Pediatrics.
JAMA Pediatrics July 2014 Volume 168, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Nanyang Technological University User on 06/08/2015
605
Opinion Editorial
REFERENCES 1. Wang LY, Vernon-Smiley M, Gapinski MA, Desisto M, Maughan E, Sheetz A. Cost-benefit study of school nursing services [published online May 19, 2014]. JAMA Pediatr. doi:10.1001 /jamapediatrics.2013.5441. 2. Johannesson M, Jönsson B, Karlsson G. Outcome measurement in economic evaluation. Health Econ. 1996;5(4):279-296. 3. Shannon RA, Kubelka S. Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, part 2. NASN Sch Nurse. 2013;28(5):222-226. 4. O’Dell C, O’Hara K. School nurses’ experience with administration of rectal diazepam gel for seizures. J Sch Nurs. 2007;23(3):166-169. 5. Supreme Court of California. American Nurses Association v Tom Torlakson (Superintendent), American Diabetes Association (S184583), Sacramento, CA. August 12, 2013. http://www.cde.ca.gov/ls/he/hn/documents /anavtorlakson2013.pdf. Accessed February 25, 2014. 6. Maughan E, Adams R. Educators’ and parents’ perception of what school nurses do: the influence of school nurse/student ratios. J Sch Nurs. 2011;27 (5):355-363. 7. Funari M. Detecting symptoms, early intervention, and preventative education: eating
disorders & the school-age child. NASN Sch Nurse. 2013;28(3):162-166. 8. Schoessler S, White MV. Recognition and treatment of anaphylaxis in the school setting: the essential role of the school nurse. J Sch Nurs. 2013; 29(6):407-415. 9. Zacharski S, DeSisto M, Pontius D, Sheets J, Richesin C. For your information: management in the school setting: position statement. NASN Sch Nurse. 2013;28(5):263-265. 10. Pryjmachuk S, Graham T, Haddad M, Tylee A. School nurses’ perspectives on managing mental health problems in children and young people. J Clin Nurs. 2012;21(5-6):850-859. 11. Ramos MM, Greenberg C, Sapien R, Bauer-Creegan J, Hine B, Geary C. Behavioral health emergencies managed by school nurses working with adolescents. J Sch Health. 2013;83(10):712-717. 12. Rodriguez E, Rivera DA, Perlroth D, Becker E, Wang NE, Landau M. School nurses’ role in asthma management, school absenteeism, and cost savings: a demonstration project. J Sch Health. 2013;83(12):842-850.
orientation and gender identity/expression (sexual minority students): school nurse practice. NASN Sch Nurse. 2013;28(2):112-113. 15. Boudreaux S, Broussard L. Sudden cardiac arrest in schools: the role of the school nurse in AED program implementation. Issues Compr Pediatr Nurs. 2012;35(3-4):143-152. 16. Gleeson C. School nurses’ workloads: how should they be prioritised? Community Pract. 2009; 82(1):23-26. 17. Chabot G, Gagnon MP, Godin G. Redefining the school nurse role: an organizational perspective. J Health Organ Manag. 2012;26(4-5):444-466. 18. Guttu M, Engelke MK, Swanson M. Does the school nurse-to-student ratio make a difference? J Sch Health. 2004;74(1):6-9. 19. Cotton L, Brazier J, Hall DMB, et al. School nursing: costs and potential benefits. J Adv Nurs. 2000;31(5):1063-1071. 20. Durant BV, Gibbons LJ, Poole C, Suessmanm M, Wyckoff L. NASN position statement: caseload assignments. NASN Sch Nurse. 2011;26(1):49-51.
13. Brewin D, Koren A, Morgan B, Shipley S, Hardy RL. Behind closed doors: school nurses and sexual education. J Sch Nurs. 2014;30(1):31-41. 14. Bradley B, Kelts S, Robarge D, Davis C, Delger S, Compton L. NASN position statement: sexual
The Downside of Increased Cost Sharing Aaron E. Carroll, MD, MS
From 1971 through 1982, the RAND Corporation conducted the most comprehensive randomized clinical trial of health insurance ever performed.1 The investigators randomized more than 2700 families and 7700 individuals to 1 of 5 health insurRelated article page 649 ance plans with different levels of cost sharing. The major finding of the study was that increased cost sharing, or making people pay more out-ofpocket for their care, led people to spend less on health care. They also found that increased cost sharing did not, in general, lead to worse health outcomes.1 Since publication of the RAND Health Insurance Experiment findings, reduced health care spending as a result of increased cost sharing has become an accepted fact. Namely, people are more reluctant to spend their own money than someone else’s. However, one of the major limitations of the RAND study was that it contained mostly healthy people. Some investigators argue that the sickest people dropped out of the experiment voluntarily, thus skewing the population.2 Furthermore, healthy people almost by definition are going to be fine in the short term with less health care. Finding ways to get them to spend less is a good thing. What about people who are unhealthy? A less reported, but still important, finding of the RAND study was that poorer people with hypertension had significantly increased mortality. They likely avoided necessary care, which led to worse health outcomes.3 Cost sharing has very 606
different implications for people with chronic conditions. They need care, and if we incentivize them to avoid it, then outcomes can get worse. Cost sharing is the subject of a study by Fung et al,4 who conducted a telephone survey of 769 parents of children with asthma who were aged 4 to 11 years. They asked the parents about how they sought care for their child’s condition. Specifically, they gathered data on how financial stress and costs changed how they sought care. Their findings are not surprising, given our prior knowledge about cost sharing. Families with higher levels of cost sharing were more likely to avoid or delay office and emergency department visits. They were more likely to forgo care. They were also more likely to borrow money or cut back on necessities to afford the care they could give to their children. This finding should give all of us pause. These are children with asthma. The care they are avoiding, delaying, or forgoing is necessary care. We all know that when it comes to asthma, preventing exacerbations is better than treating them. Most surprising was who was most affected by cost sharing. The literature is replete with studies that show that Medicaid is associated with worse outcomes than private insurance. 5 In this case, however, Medicaid was not the underperformer. For the most part, Medicaid and the State Children’s Health Insurance Program have little, if any, cost sharing, which removes the financial burden for people to obtain care. Com-
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