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Corticosteroid Prescription Filling for Children Covered by Medicaid Following an Emergency Department Visit or a Hospitalization for Asthma
William O. Cooper, MD, MPH;
Gerald B. Hickson, MD
Arch Pediatr Adolesc Med. 2001;155:1111-1115.
ABSTRACT
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Objective To identify predictors of corticosteroid prescription filling following
an emergency department (ED) visit or a hospitalization for asthma.
Design A retrospective cohort study.
Patients Tennessee children (defined as those aged 2-17 years in this study)
covered by Medicaid were included in the cohort if they had an ED visit or
a hospitalization for asthma between July 1, 1995, and December 31, 1997.
Main Outcome Measures Prescriptions filled in the child's name for an oral corticosteroid
within 7 days of the latest ED visit or hospitalization for asthma.
Results Of 6035 Tennessee children covered by Medicaid with an ED visit for
asthma and of 2102 covered by Medicaid with a hospitalization for asthma during
the study period, less than half (44.8% following an ED visit and 55.5% following
a hospitalization) had prescriptions filled for oral corticosteroids within
7 days. Factors independently predicting a child's not having an oral corticosteroid
prescription filled included older age, black race, and residence in rural
regions of the state. Conversely, children with oral corticosteroid prescriptions
in the previous 6 months were more likely to have oral corticosteroid prescriptions
filled following an ED visit for asthma, and children with more than 3 ß-agonist
prescriptions in the previous 6 months were more likely to have oral corticosteroid
prescriptions filled following a hospitalization for asthma.
Conclusions Overall, fewer than half of Tennessee children covered by Medicaid had
an oral corticosteroid prescription filled following an ED visit or a hospitalization
for asthma. Age, race, and county of residence predicted failure to have a
prescription filled. Further study is needed to determine whether variations
in corticosteroid prescription filling relate to physician practice, family
behavior, or both.
INTRODUCTION
DESPITE SPECIFIC guidelines for optimizing asthma management,1 many children do not receive recommended care. Certain
groups of children are less likely to receive appropriate care than others,
including disadvantaged and minority children2, 3
and children receiving treatment in certain settings such as neighborhood
health clinics and hospital-based clinics.2
One potential point for improving care delivery is the provision of
systemic corticosteroids for asthma exacerbations. Systemic corticosteroids
are a mainstay of treatment for children with acute asthma exacerbations.1 Because asthma exacerbations are relatively well-defined
events, the intervention is short-term, and the filling of prescriptions is
relatively easy to track, optimizing corticosteroid prescription filling for
children with acute asthma exacerbations is an attractive point for intervention.
Interventions targeted at corticosteroid filling could serve as models for
interventions at other points in asthma therapy.
This study identifies children (defined as those aged 2-17 years in
this study) who do not have corticosteroid prescriptions filled following
an asthma emergency department (ED) visit or hospitalization. Identification
of groups less likely to receive recommended care would allow for focused
education for physicians and families, and might allow for the identification
and reduction of barriers to prescription filling.
PATIENTS AND METHODS
STUDY COHORT AND SELECTION OF COVARIATES
The cohort included 2- to 17-year-old children enrolled in Tennessee
Medicaid between July 1, 1995, and December 31, 1997, who had a hospital discharge
diagnosis of asthma or an ED visit with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision, Clinical
Modification, code 493)4 or a primary
diagnosis of a respiratory illness and a secondary diagnosis of asthma.5 These criteria were chosen to have a high sensitivity
for identifying a child with an asthma exacerbation, although it is possible
that these criteria also included children with an asthma exacerbation not
severe enough to warrant a course of oral corticosteroids.
To be included in the study, children were required to have complete
sociodemographic information in the enrollment file (age, race, sex, and county
of residency at the index date). The National Institutes of Health guidelines
for the care of asthma include age as a determining factor for initiating
certain asthma medications.1 Race was included
as a covariate based on previously described disparities in access to asthma
care for minority children2, 3
and on sociocultural beliefs leading to differences in use of asthma medications
in minority families.6 Regional differences
in asthma care have also been described; therefore, county of residence was
identified for each child in the cohort.7, 8
The use of asthma health care services and the filling of prescriptions
for asthma medications in the previous 6 months have been shown to predict
subsequent use of asthma services.5 Thus, the
use of asthma health care services and the filling of prescriptions for asthma
medications serve as markers of asthma severity.5
Asthma severity measures used in the present study included the number of
ED visits for asthma, hospitalizations for asthma, oral corticosteroid prescriptions,
and ß-agonist prescriptions in the 6 months before the index ED visit
or hospitalization for asthma.
To allow for complete ascertainment of study outcomes, cohort members
were required to be continuously enrolled in Medicaid for the 6 months before
the index ED visit or hospitalization and for the 12 months after the index
event.9 Cohort members were required to have
12 months of continuous follow-up to adequately define health services use
following the index event as part of a larger study.
ORAL CORTICOSTEROID USE
Pharmacy files were searched to identify oral corticosteroid prescriptions
(matching national drug codes from the Food and Drug Administration's National
Drug Codes Classification to pharmacy claims data)10, 11
filled in the name of cohort members within 7 days of the index visit. Oral
corticosteroid dosage forms included prednisone, prednisolone, and methylprednisolone.
For hospitalizations, the discharge date was considered as the start of the
follow-up period. The primary study outcome was a child having a prescription
for an oral corticosteroid filled within 7 days following the index visit.
ANALYSIS
Strata were defined by study covariates, including sociodemographic
variables (age, race, sex, and county of residence12)
and asthma severity variables.
Univariate comparisons of oral corticosteroid prescription filling were
performed by comparing proportions of children having the primary study outcome
across strata.  2 Comparisons of study outcomes were performed,
with P<.05 considered to represent statistical
significance.
Multivariate logistic regression was used to compare the occurrence
of corticosteroid filling across strata, with adjustments made for sociodemographic
variables thought to influence prescription filling and asthma severity variables.
The category of 5 to 9 years served as the reference for age, white as the
reference for race, urban as the reference for county, and west Tennessee
as the reference for region of the state. For the asthma severity variables,
having no prior ED visits or hospitalizations for asthma, having less than
3 ß-agonist prescriptions, and having no corticosteroid prescriptions
served as the references.
All analyses were performed using SAS statistical software, version
6.12 (SAS Institute Inc, Cary, NC), running under an operating system (Windows
NT 4.0; Microsoft Corp, Redmond, Wash) on a personal computer (Pentium P6;
Intel Corp, Santa Clara, Calif).
This study was approved by the Vanderbilt University institutional review
board.
RESULTS
STUDY COHORT
There were 6035 children enrolled in Medicaid during the study period
who had an ED visit for asthma; 2102 children had a hospitalization for asthma.
Of children with an ED visit for asthma, most (67.8%) were younger than 10
years, 45.0% were black, and 55.6% resided in an urban county (Table 1). More children hospitalized with an asthma diagnosis were
younger than 10 years (75.2%), while a similar proportion of hospitalized
children were black or resided in an urban county.
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Table 1. Characteristics of Tennessee Children Covered by Medicaid
With an ED Visit or a Hospitalization for Asthma*
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UNIVARIATE COMPARISONS OF CORTICOSTEROID USE
Overall, only 44.8% of children with an ED visit for asthma and 55.5%
of children with a hospitalization for asthma had an oral corticosteroid prescription
filled within 7 days of the index event (Table 2). In univariate comparisons for ED visits and hospitalizations,
older children (aged 14-17 years) were less likely to have oral corticosteroid
prescriptions filled than were younger children. In addition, black children
were less likely to have an oral corticosteroid prescription filled than were
white children and children of other races. There was much variation in corticosteroid
prescription filling according to the child's county of residence, with fewer
children having prescriptions filled in the predominantly rural east and northeast
regions of the state and more having prescriptions filled in the other regions.
For asthma severity in the 6 months before the index event, prior ED visits
for asthma, prior hospitalizations for asthma, having an additional oral corticosteroid
prescription, and having 3 or more ß-agonist prescriptions were related
to corticosteroid prescription filling following an ED visit. Only having
3 or more ß-agonist prescriptions was related to corticosteroid prescription
filling following a hospitalization for asthma.
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Table 2. Corticosteroid Prescriptions Filled for Tennessee Children
Covered by Medicaid Following an ED Visit or a Hospitalization for Asthma*
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MULTIVARIATE COMPARISONS OF ORAL CORTICOSTEROID USE
When controlling for age, race, county, region, and asthma severity
characteristics in multivariate analysis, factors related to a child having
an oral corticosteroid prescription filled within 7 days of the index visit
included age, race, county of residence, and asthma medication prescription
filling before the index visit (Table 3). Older age, black race, and residence in rural regions of the
state independently predicted failure to have prescriptions filled following
both types of encounters. Neither previous ED visits nor previous hospitalizations
for asthma predicted the filling of corticosteroid prescriptions after the
index visit in multivariate analyses. Corticosteroid use in the previous 6
months positively predicted subsequent corticosteroid prescription filling
following an ED visit for asthma, while having 3 or more ß-agonist prescriptions
filled positively predicted corticosteroid prescription filling following
a hospitalization for asthma.
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Table 3. Factors Related to a Child Having a Corticosteroid Prescription
Filled Following an ED Visit or a Hospitalization for Asthma Among Tennessee
Children Covered by Medicaid*
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COMMENT
Fewer than half of Tennessee children covered by Medicaid had an oral
corticosteroid prescription filled following an ED visit or a hospitalization
for an asthma exacerbation. The results of the present study are troubling,
but consistent with findings in studies13 of
adults covered by Medicaid. Even though patients covered by Medicaid seek
health care for asthma, few have corticosteroid prescriptions filled during
an asthma exacerbation despite consensus guidelines1
supporting the use of systemic corticosteroids for asthma exacerbations. It
is important to identify potential explanations for the variation from recommended
asthma care seen among Tennessee children covered by Medicaid.1
Several characteristics, including race, age, county of residence, and prior
prescription filling, predicted a child's having a corticosteroid prescription
filled.
The finding that black children were significantly less likely to have
corticosteroid prescriptions filled than were white children or children of
other races was consistent with findings in other studies3, 14
describing disparities in asthma care according to race. Bosco et al3 identified that black children with asthma enrolled
in Michigan Medicaid had more frequent health care encounters, but filled
prescriptions for all asthma drugs less frequently. In the study by Bosco
et al, black children were less than half as likely to have a corticosteroid
prescription filled. The study by Bosco et al did not link prescriptions to
health care encounters, so it was not possible to determine the asthma severity
of children in that study. In a study of quality of care for children with
asthma, Finkelstein et al14 identified marked
differences in the prescribing of ß-agonists after hospital discharge
for black and Hispanic patients compared with white patients. The inclusion
of asthma severity indicators and the focus on corticosteroid use are unique
aspects of the present study.
Several factors may contribute to the differences in prescribing by
race identified in the present study. There may have been differences in the
writing of prescriptions for certain groups of children, a notion supported
by the findings of Finkelstein et al, who found that children of racial minorities
were less likely to have received maximal effective prevention therapy before
hospital admission. It is also possible that there were differences in family
adherence with physician recommendations, resulting in some families not filling
prescriptions, even though they were written. Other studies6, 15
have suggested that lack of adherence among families of children with asthma
stems from health beliefs relative to the effectiveness and safety of asthma
medications. Given evidence from previous studies16, 17
that asthma is more severe in black children, the disparities in prescription
filling in the present study are even more striking and warrant careful examination.
The present study also identified a negative relationship between adolescence
and the filling of oral corticosteroid prescriptions. Studies18, 19
documenting overuse of ß-agonists among adolescents dying from asthma
support differences in treatment adherence among older children. Adolescence
is a period of transition from a child's dependence to the independence of
adulthood. During this time, adolescents are driven by the need for peer acceptance,
and compliance with a medication regimen places an adolescent at risk of being
"different."20 Parents may be less likely to
assert influence on an adolescent, particularly if an older child is viewed
as less vulnerable than a younger child or if continued conflicts over taking
medication have negative effects on family dynamics.20
Family dynamics might thus lead to a family's reluctance to fill corticosteroid
prescriptions that they believe are not likely to be taken by their child.
County of residence predicted a child's having a corticosteroid prescription
filled, with children residing in rural counties being less likely to have
corticosteroid prescriptions filled. In addition, children in predominantly
rural regions of the state were less likely to have corticosteroid prescriptions
filled. Regional differences in asthma care have been documented previously7 and are thought to relate to differences in prehospitalization
asthma care.8 It is possible that slower diffusion
of knowledge into rural areas with subsequent less knowledge of state-of-the-art
asthma care might relate to less physician adherence to asthma guidelines.21 The delivery of continuing medical education to rural
physicians may be different from that delivered to urban physicians, resulting
in differences in awareness of treatment guidelines.21, 22
An additional finding of the present study was that corticosteroid and ß-agonist
prescription filling in the previous 6 months predicted subsequent corticosteroid
prescription filling. This was similar to results seen in a study by Diaz
et al23 of medication use among children with
asthma in East Harlem, NY. In the study by Diaz et al, children with more
severe asthma who had a recent physician visit were greater than 3 times more
likely to use anti-inflammatory medications. Families may be more likely to
accept corticosteroid therapy as being effective in exacerbations if they
have experienced benefit previously or if they have an appreciation for the
severity of their child's asthma based on prior experience.
Limitations of our study include the inability to determine whether
a prescription was written and not filled by the family or was never written.
In addition, even if a prescription was filled, we were unable to determine
if a child took the medication as prescribed.
It is not likely that medication delivery was missed in the study because
of children receiving corticosteroids or "sample packs" directly from a physician
without a prescription, which would not be captured in the pharmacy databases.
Tennessee's Medicaid program is administered through several managed care
companies, with strict formulary guidelines. In a survey of the institutions
in the state that provide the bulk of children's services, it was not routine
practice among Tennessee health care facilities to dispense entire courses
of a medication without a prescription. In addition, for hospitalizations
for asthma, it is not likely that children received a complete course of corticosteroids
while in the hospital. More than 95% of the children with a hospitalization
for asthma were discharged within 5 days of admission, and 98% were discharged
by 7 days, so that few children were hospitalized long enough to complete
a typical 5- to 7-day course of corticosteroids.
An additional limitation of the study relates to the asthma definition
used. While it can be argued that any asthma exacerbation severe enough to
warrant hospitalization deserves systemic corticosteroids, some ED visits
for asthma may not be severe enough to warrant corticosteroids. Furthermore,
there may be important differences among the groups defined by the study covariates
(eg, age and race) that relate to visiting the ED for less severe asthma symptoms.
It is not likely that lack of asthma severity completely explains the findings
of this study.
This study suggests that improvements in the care of children with asthma
are likely to require interventions on multiple levels. Educating physicians
about appropriate asthma care and ensuring that perceived barriers to guideline
compliance are addressed will help to improve physician prescribing behavior.21 Educating physicians requires modification of continuing
medical education efforts, with special attention to the needs of physicians
in rural areas.21, 22 Data systems,
like those used to conduct the present study, might be used to provide regular
feedback to physicians who might not be writing prescriptions appropriately
and/or to physicians who might prescribe appropriately but whose patients'
families may not be adherent.24 Other efforts
might be directed at family-based barriers to care, such as family health
beliefs,6 and at environmental and financial
hindrances faced by families,15 to allow for
better communication of asthma care objectives to families.6
Public health initiatives that reduce administrative barriers to prescription
filling for families living with numerous social stressors might improve access
to appropriate prescription medicines.
Determining ways of improving the use of corticosteroids among all children
and especially among higher-risk children is important. Given the findings
of this study that less than 50% of children had an oral corticosteroid prescription
filled following an asthma exacerbation severe enough to warrant ED care or
a hospitalization, it is likely that interventions will need to be implemented
on multiple levels. Given the huge impact that asthma has on individual children
and their families, and on society as a whole, interventions to improve asthma
care are imperative.
AUTHOR INFORMATION
Accepted for publication April 13, 2001.
This study was supported in part by grant 036816 from the Robert Wood
Johnson Foundation Generalist Physician Faculty Scholars Program, Princeton,
NJ (Dr Cooper).
Presented at the Pediatric Academic Societies Meeting, Boston, Mass,
May 14, 2000.
What This Study Adds
Despite specific guidelines for optimizing asthma management, many children
do not receive recommended care, including disadvantaged and minority children
and children receiving treatment in certain health care settings. One point
for improving care for children with asthma is the provision of systemic corticosteroids
for children with acute asthma exacerbations. Assessing whether children with
an asthma exacerbation have a pharmacy claim for systemic corticosteroids
would provide a means to assess adherence to asthma guidelines and would provide
opportunities for targeted interventions for certain health care settings
and populations.
Less than half of the children in the study with an emergency department
visit for asthma and just slightly more than half of those with a hospitalization
for asthma had prescriptions filled for systemic corticosteroids following
the encounter. Characteristics of the child (age, race, and county of residence)
and previously validated asthma severity measures (use of asthma medications
in the past 6 months) independently predicted whether a child had a corticosteroid
prescription filled for emergency department visits and hospitalizations.
Interventions are, thus, needed on multiple levels to optimize the care of
children with asthma.
From the Division of General Pediatrics,
Vanderbilt Children's Hospital, Vanderbilt University Medical Center,
Nashville, Tenn.
Corresponding author and reprints: William O. Cooper, MD, MPH, Division
of General Pediatrics, Vanderbilt Children's Hospital, Suite 5028, Medical
Center East, Nashville, TN 37232-8555 (e-mail: william.cooper{at}mcmail.vanderbilt.edu).
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