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Underuse of Controller Medications Among Medicaid-Insured Children With Asthma
Jonathan A. Finkelstein, MD, MPH;
Paula Lozano, MD, MPH;
Harold J. Farber, MD;
Irina Miroshnik, MS;
Tracy A. Lieu, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:562-567.
Background National guidelines recommend daily use of controller medications for
children with persistent asthma. Although studies suggest low rates of controller
use, little is known about predictors of underuse among low-income children
in whom asthma morbidity is greatest.
Objectives To determine the frequency of underuse of controller medications among
Medicaid-insured children in a variety of managed care arrangements, and to
examine demographic factors and processes of asthma care associated with underuse.
Design Cross-sectional telephone survey of parents of children and adolescents
aged 2 to 16 years with asthma, insured by Medicaid, and enrolled in 1 of
5 managed care plans. The main outcome was parent-reported underuse of controllers
among children with persistent asthma. Survey items included demographic factors
and reports of specific processes of care. Current symptom level was determined
by recall of the number of days with symptoms in the previous 14 and by the
Physical Function Score of the American Academy of Pediatrics (AAP) Child
Health Status Assessment for Asthma. Logistic regression was used to identify
factors independently associated with underuse.
Results The response rate was 66%, with 1648 children included in the analysis;
1083 were classified as having persistent asthma. Of these, 73% were underusers
of controller therapy, with 49% reporting no controller use and 24% reporting
less than daily use. A multivariate model that adjusted for age, managed health
care organization, and AAP Physical Function Score found that black (odds
ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.4) or Latino (OR, 2.2;
95% CI, 1.3-3.8) race were associated with underuse and that parental education
beyond high school was protective (OR, 0.6; 95% CI, 0.4-0.8). Having a primary
care physician (OR, 0.4; 95% CI, 0.2-0.8), written action plan (OR, 0.5; 95%
CI, 0.4-0.7), or a follow-up visit (OR, 0.5; 95% CI, 0.4-0.8) and having seen
an asthma specialist (OR, 0.5; 95% CI, 0.4-0.7) were associated with lower
rates of underuse.
Conclusions Underuse of controller medications among Medicaid-insured children is
widespread. Racial minorities and children whose parents are less educated
are at higher risk for underuse. Patients who have received action plans or
had follow-up visits or specialty consultations are less likely to be symptomatic
underusers of controller medications.
From the Department of Ambulatory Care and Prevention, Harvard Medical
School and Harvard Pilgrim Health Care (Drs Finkelstein and Lieu and Ms Miroshnik),
and the Department of Pediatrics, Harvard Medical School (Dr Finkelstein),
Boston, Mass; the Center for Health Studies, Group Health Cooperative, and
the University of Washington, Seattle (Dr Lozano); and the Department of Pediatrics,
Kaiser Permanente Vallejo Medical Center, Vallejo, Calif (Dr Farber).
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