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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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