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Use of Inhaled Anti-inflammatory Medication in Children With Asthma in Managed Care Settings
Robert J. Adams, MBBS, MD;
Anne Fuhlbrigge, MD, MS;
Jonathan A. Finkelstein, MD, MPH;
Paula Lozano, MD, MPH;
James M. Livingston, MBA;
Kevin B. Weiss, MD;
Scott T. Weiss, MD, MS
Arch Pediatr Adolesc Med. 2001;155:501-507.
ABSTRACT
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Background Many factors affect use of inhaled therapy in asthma. Relatively little
is known about current patterns of use of anti-inflammatory medication in
children with asthma and whether variations occur with age and use of bronchodilator
medication.
Objective To study the factors associated with dispensing of anti-inflammatory
(controller) asthma medication to children in 3 managed care organizations
(MCOs).
Methods Using automated databases, a 1-year cross-sectional study of children
with asthma aged 3 to 15 years cared for in 3 MCOs was used to evaluate the
association of age and other factors with controller medication use.
Results A total of 13 352 children were studied. Significantly fewer children
aged 3 to 5 years were dispensed any ( 1) controller medication than older
children (P<.001). Among children dispensed 6
or more ß-agonists, only 39% also received 5 or more controller dispensings,
with adolescents significantly less likely than younger children to receive
5 or more controllers (33%; P<.001). Significant
differences were seen among MCOs in proportions of patients dispensed controller
medication. In a multiple logistic regression model, controlling for frequency
of ß-agonist dispensing and MCO, significantly lower dispensing of any
controller medication was seen for those aged 3 to 5 years (odds ratio [OR],
0.8; 95% confidence interval [CI], 0.7-0.9) and for girls (OR, 0.9; 95% CI,
0.8-0.96). In contrast, for repeated (5) controller dispensing there were
significantly fewer dispensings to adolescents (OR, 0.7; 95% CI, 0.6-0.9)
and girls (OR, 0.8; 95% CI, 0.7-0.9).
Conclusions There may be differences in the use of preventive asthma medication
in children that are affected by age, sex, and health care organization. Few
children with frequent symptoms are using controllers regularly, as is recommended
by national guidelines.
INTRODUCTION
ASTHMA remains the most common chronic disease in children and a major
cause of morbidity and health care costs nationally and internationally.1, 2 The Guidelines for the Diagnosis and
Treatment of Asthma, developed by the National Asthma Education and Prevention
Program (NAEPP) in 1991,3 and recently revised,4 emphasize the use of preventive or anti-inflammatory
(controller) medications for the treatment of all children with persistent
asthma. These guidelines have been widely disseminated, with a recent survey
of 700 health care providers, including 512 physicians, showing that 89% of
physicians say that they are aware of the guidelines, with 80% attempting
to follow them at least "most of the time" in their everyday practice.5 However, it has been demonstrated that process of
translating their recommendations into clinical practice in the United States
has been slow.6, 7
In recent years, significant increases in a number of countries in the
use of anti-inflammatory therapy, principally inhaled corticosteroids (ICSs),
have been associated with reductions in asthma morbidity and mortality.6, 8 In the United States there have been
few published studies in the clinical literature on dispensing patterns for
controller therapy for asthma in general pediatric populations and the factors
associated with their use. Using data from 1993, shortly after the release
of the NAEPP guidelines, Buchner et al7 found
that fewer than one third of children and adolescents with asthma managed
in 5 geographically diverse managed care organizations (MCOs) received 1 or
more prescriptions for anti-inflammatory medicine during a year, with fewer
than 12% receiving sufficient canisters to suggest long-term use. Goodman
et al9 found that children in one MCO were
more likely to have been dispensed 3 or more controller inhalers per year
in 1984, prior to the release of national guidelines, than in 1993 shortly
following guideline release. They reported that use of inhaled controller
medications was particularly low in adolescents who were high ß-agonist
users.9 National survey data have found no
change in reported use of inhaled controller therapy when the results from
1991 through 1994 are compared with the period 1988 through 1991.10 The authors reported that children younger than 6
years were more likely to receive inadequate therapy, and that most children
receiving inadequate controller therapy were not poor.10
In a small study of inner-city children, 39% with a recent hospitalization
or daily use of ß-agonists were using inhaled anti-inflammatory medication
regularly.11 Several recent studies focusing
on adults have also indicated underuse of ICSs in people with asthma.12, 13, 14 These studies in
pediatric populations date only from the period shortly following the initial
dissemination and promotion of the guidelines. In addition, they are limited
by the use of self-reported data using questions that do not allow estimation
of whether children are regular or sporadic users of medication, or by the
use of data from a single MCO. There is little recent information regarding
the pattern of use of inhaled controller therapy in children now that sufficient
time has elapsed since the release of the guidelines to allow for dissemination
and integration into clinical practice.
This study examines children enrolled in 4 different care delivery systems
within 3 geographically diverse MCOs that care for a total population of approximately
2 million people. These organizations are participating in the multicenter
Pediatric Asthma Care–PORT (PAC-PORT II) trial of strategies to improve
pediatric asthma health outcomes. Our aim was to examine some of the factors
associated with the patterns of use of asthma controller therapy. We anticipated
that adolescents would be less likely to be regular users of controllers,15 whereas preschool-age children would be less likely
to be initiated on ICSs than older children,10
because no nebulized ICS formulations were available during the study period
and because of concern regarding the potential side efffects of ICS in young
children. We examined whether these practice patterns were continuing despite
more than a decade since the initial dissemination of the guidelines.
POPULATION AND METHODS
SETTING
This is a 1-year cross-sectional analysis of data collected for the
PAC-PORT II trial, a multicenter trial of implementation strategies for the
NAEPP guidelines for the diagnosis and management of children with moderate
to severe asthma. As part of the initial phase of this project, clinical care
for children with asthma within the primary care practice settings at each
of the health plans was characterized.
All subjects were members of one of the MCOs participating in the PAC-PORT
II, located in 3 geographically varied US metropolitan areas. Each MCO provides
a number of managed care products. We report data from 4 different care delivery
systems within the 3 MCOs. The 4 systems are herein referred to as MCOs 1
to 4. MCO 1 is organized as a staff-model, closed panel MCO with approximately
400 000 enrollees. MCOs 2 and 3 are 2 formerly separate divisions of
approximately equal size that have now been amalgamated into one organization,
with an overall enrollment of approximately 1.2 million people. We report
results from these 2 divisions separately. MCO 2 is a group-model MCO and
MCO 3 is a network-model system. Data for MCO 4 come from only the staff-model
system of this mixed-model MCO with about 400 000 members. Approximately
90% of all members of each plan have prepaid drug coverage that provides up
to a month's supply of medicine for a nominal copayment ($5-$10 per prescription).
During the study period (July 1, 1996, to June 30, 1997), asthma outreach
programs were in various stages of development in the 3 MCOs. These programs
were scheduled to include patient and staff education and follow-up programs
for individuals with more serious asthma.
The study MCOs maintain computerized information systems that capture
basic demographic data and claims files for all hospitalizations and emergency
department visits. Automated pharmacy records maintained by or available at
all sites contain detailed information on all medications dispensed via prescription
at all pharmacies.
STUDY POPULATION
The study population consisted of all children enrolled in the 4 MCOs
aged 3 to 15 years with at least 1 diagnosis of asthma (International Classification of Diseases, Ninth Revision, Clinical Modification16 codes 493.00-493.99) listed for a
hospitalization, emergency department visit, or ambulatory encounter (ie,
provider-diagnosed asthma), from July 1, 1996, to June 30, 1997. Only persons
who were continuously enrolled for the 12-month study observation period (ie,
July 1, 1996 to June 30, 1997) and who had prepaid drug coverage were included
as eligible for analysis.
MEDICATIONS
The frequency of controller therapy dispensing was calculated for each
type of drug for each individual by summing the number of prescriptions dispensed.
Asthma controller therapy included ICSs (referred to as "inhaled steroids")
and inhaled cromolyn sodium or nedocromil (referred to as "cromolyn"). Oral
antileukotrienes were rarely dispensed at any age, and have been omitted from
the analysis. "ß-Agonists" included inhaled or pediatric oral preparations
and included anticholinergics, but excluded long-acting ß-agonists such
as salmeterol, as use of these drugs during the period under study was minimal.
STATISTICAL ANALYSIS
The main outcome of interest was frequency of asthma controller therapy
dispensing. The frequency of ß-agonist dispensing served as a surrogate
for asthma severity and was used as the main variable for stratification in
the analysis. Potential covariates included age, sex, and MCO. Information
on race was unavailable for a substantial proportion of the population and
was therefore not considered in this analysis. Pharmacy data included any
initial dispensing and refills of all prescription medications.
Differences in the proportion of children dispensed any controller therapy
in each stratum were assessed for significance by  2 tests
and Mantel-Haenszel methods. ß-Agonist dispensing rates were collapsed
into 4 categories (0, 1-2, 3-5, 6 dispensings). These categories were
viewed as proxies for measurements of disease severity. This method has been
successfully used in previous studies to stratify risk of morbidity.17, 18 Leone et al19
reported a monotonic relationship between a pharmacy-based severity classification
and future inpatient resource utilization for asthma. Six or more dispensings
of ß-agonists provides at least 1200 inhalations, at an average during
1 year of more than 3 inhalations per day. The current guidelines are clear
in their recommendation that children who require frequent use of ß-agonists
should also be maintained with controller medication. Age was also divided
into 4 groups (3-5, 6-8, 9-11, and 12-15 years). These categories were chosen
so that preschool-age children and adolescents could be examined separately,
and to ensure groups of approximately equal size.
Controller medications were not weighted for potency, as fluticasone
propionate accounted for only 5% of controller dispensings and budesonide
was not being used during this period, and recommended doses of other ICSs
are similar to each other. Multiple logistic regression was used to model
controller therapy dispensing. We were interested in the total number of children
receiving controllers and those getting them more regularly. We examined repeated
dispensings, since current management recommendations are for long-term use
in children with persistent asthma.4 Therefore,
separate models were developed for the outcomes of (1) any controller dispensing,
(2) 3 or more controller dispensings, and (3) 5 or more controller dispensings.
Three controller canisters during 1 year would provide less than 2 inhalations
per day, while 5 controller canisters are the minimum number that could indicate
nearly daily use of medication, at an average of 2 to 3 inhalations per day.
Differences by patient age were evaluated by stratified analysis and by inclusion
of interaction terms in the logistic model.
Approval for this study was obtained from institutional review boards
at each study site.
RESULTS
Eligibility criteria were satisfied by 13 352 children, with 3082
children from MCO 1, 2852 from MCO 2, 6033 from MCO 3, and 1385 from MCO 4.
The average age of the children was 9.3 years, and there was a predominance
of boys (59%) in the sample overall. The distribution of age and sex was similar
across MCOs.
ANALYSIS BY AGE
Dispensing of controller therapy varied among age groups. Significantly
fewer children aged 3 to 5 years received 1 or more dispensings of a controller
therapy than did children in older age groups (P<.01)
(Figure 1). Although a similar proportion
of 3- to 5-year-olds were dispensed cromolyn as 6- to 8-year-olds, fewer younger
children were dispensed ICSs (Figure 1).
In all age groups the proportion of children receiving controllers increased
with more frequent dispensing of ß-agonists. Overall, 60% of children
who received 3 or more ß-agonists also received some controller medication
(Figure 2), and this figure increased
to 77% in those with 6 or more ß-agonist dispensings (Figure 3). The pattern of age differences in controller use changed
among children with more frequent dispensing of ß-agonists. Among children
who received 6 or more ß-agonists, a similar proportion of 3- to 5-year-olds
(70%) as older children (74%) received a controller medication (Table 1). Preschool-age children in the 3 or more and 6 or more ß-agonist
groups continued to receive cromolyn more frequently than older children,
and more frequently than they were dispensed ICSs. However, in multivariate
analysis, controlling for frequency of ß-agonist dispensing, sex, and
MCO, 3- to 5-year-olds were less likely to receive a dispensing of controller
therapy than older children (odds ratio [OR], 0.8; 95% confidence interval
[CI], 0.7-0.9; P = .01) (Table 2).
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Figure 1. Proportion of children with 1
or more dispensings of inhaled corticosteroids (ICS), cromolyn sodium, or
either for each age group.
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Figure 2. Proportion of children with 1
or more dispensings of inhaled corticosteroids (ICS), cromolyn sodium, or
either among those with 3 or more ß-agonist dispensings for each age
group.
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Figure 3. Proportion of children with 1
or more dispensings of inhaled corticosteroids (ICS), cromolyn sodium, or
either, among those with 6 or more ß-agonist dispensings for each age
group.
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Table 1. Frequency of Children With Asthma in Different Age Groups
Who Were Dispensed Controllers at Differing Rates, Among Only Those With 6
or More ß-Agonist Dispensings
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The pattern of repeated (3 or 5) controller dispensings showed
few children received controllers regularly, even among children with frequent ß-agonist
use (Table 3). Only 12% of all
children were dispensed 5 or more canisters of controller over 12 months.
Few children at any age who were infrequent ß-agonists users were regular
users of controllers (Table 4).
Among those dispensed 6 or more ß-agonists, 58% received 3 or more, and
39% received 5 or more controllers of any type. Significantly fewer adolescents
(12- to 15-year-olds) than younger children who received 6 or more ß-agonists
were dispensed either 3 or more (54% vs 61%; P =
.001), or 5 or more controllers (33% vs 43%; P<.001).
Only 21% of adolescents in this group of frequent ß-agonists users received
5 or more dispensings of ICSs. This pattern was confirmed in multivariate
analysis, controlling for other factors as above. Children aged 12 to 15 years
were significantly less likely to be dispensed 3 or more (OR, 0.8; 95% CI,
0.70-0.94; P = .005) or 5 or more controllers (OR,
0.7; 95% CI, 0.6-0.9; P<.001) than younger children.
Children 6 to 8 years old were more likely to receive repeated (5) controller
dispensings than preschool-age children (OR, 1.3; 95% CI, 1.1-1.6; P = .008). When the analysis was restricted to only those who had been
dispensed some controllers (n = 5257), a similar pattern was seen. Using 3-
to 5-year-olds as the reference group, the OR for repeated (5) controller
dispensings in 12- to 15-year-olds was 0.6 (95% CI, 0.5-0.8; P<.001), and for 6- to 8-year-olds was 1.3 (1.1-1.6; P = .03) (data not shown).
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Table 3. Numbers of Children With Asthma in Different Categories of
Frequency of Controller Dispensing, Stratified by Frequency of ß-Agonist
Dispensing
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Table 4. Frequency of Children With Asthma in Different Age Groups
Who Were Dispensed 5 or More Controllers, in Different Categories of Frequency
of ß-Agonist Dispensing
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ANALYSIS BY SEX
Over the year of the study, a significantly lower proportion of girls
(37%) received any controller therapy than did boys (41%; P<.001). A difference of similar magnitude was evident across all
age groups and at all MCOs. A similar pattern was seen for repeated (5)
controller dispensing (10% vs 13%; P>.001). Among
children dispensed 6 or more ß-agonists, significantly fewer girls than
boys received any controllers (75% vs 79%; P = .006)
or repeated (5) controller dispensings (39% vs 43%; P = .005). In the group with 6 or more ß-agonist dispensings,
the sex discrepancy for repeated controller dispensing was greatest in children
aged 3 to 5 years (34% vs 48%; P<.001) and was
also seen in 9- to 11-year-olds (41% vs 46%), but was absent in 12- to 15-year-olds
(35% vs 36%). In the multivariate analyses, controlled for age, organization,
and ß-agonist use, girls were significantly less likely than boys to
receive any controller therapy (Table 2). Girls were also less likely than boys to receive 5 or more dispensings
(OR, 0.8; 95% CI, 0.7-0.9; P = .004), or 3 or more
dispensings (OR, 0.9; 95% CI, 0.80-0.97; P = .01)
of controllers. In the analysis restricted only to those dispensed some controller,
a similar result was found, with girls significantly less likely to receive
repeated (5) controller dispensing (OR, 0.8; 95% CI, 0.7-0.95; P = .03).
EFFECT OF ORGANIZATION
Differences in controller use were evident among MCOs. Children at MCO
1 were more likely than children at MCO 4 to receive ICSs (33% vs 23%; P<.05) and less likely to get cromolyn (15% vs 25%; P<.05). This pattern was seen across all age groups.
Differences in controller use among MCOs persisted among children dispensed
6 or more ß-agonists. At MCO 3, 69% who received 6 or more ß-agonists
were also dispensed at least 1 controller, compared with 85% at MCO 1 and
83% at MCO 4. The multivariate model for any controller dispensing showed
children at MCO 3 were significantly less likely than children cared for at
other MCOs to receive any controllers (Table 2). Those cared for at either MCO 1 or 2 were more likely
than those from MCO 4 to be dispensed any controller. However, the model for
repeated (5) controller dispensing showed different results. Children
from MCO 3 were significantly more likely (OR, 1.3; 95% CI, 1.1-1.7; P = .02) and those at MCO 1 less likely (OR, 0.8; 95% CI,
0.6-0.99; P = .05) than those at the reference group
of MCO 4 to be dispensed 5 or more controllers. A similar result was evident
for dispensing of 3 or more controllers. When the analysis was restricted
to those with some controller dispensing, MCO 3 children were significantly
more likely to have repeated controller dispensing (OR, 1.7; 95% CI, 1.3-2.1; P<.001) than those from MCO 1 (OR, 0.7; 95% CI, 0.6-0.98; P = .03) or the reference group of MCO 4.
COMMENT
Nearly a decade after the distribution of national guidelines for the
management of asthma, few children with symptomatic asthma use controller
therapy regularly in the diverse managed care settings that we studied. The
current NAEPP guidelines clearly recommend the regular use of controller medication
for children whose high ß-agonist use indicates symptoms throughout the
year.4 Six or more ß-agonists per year
will provide on average more than 3 inhalations per day of quick-relief medication.
Few of these children will not have persistent asthma. Although nearly three
quarters in this group were dispensed a controller at least once, only around
two fifths had 5 or more dispensings of controller. Among these children with
more frequent ß-agonist use, only a little more than half were dispensed
3 or more controllers; in no age category did the proportion dispensed 5 or
more controllers reach 50%, and in adolescents this proportion dropped to
one third. Conversely, there were few children who were regular users of controllers
but infrequent ß-agonist users, suggesting that the group with persistent
asthma who was well controlled was small.
As anticipated, children of preschool age were less likely to be initiated
on anti-inflammatory medication, and fewer adolescents were regular users
of anti-inflammatories. Our results provide similar findings to earlier studies
of overall controller use that were conducted during the first years after
the initial dissemination and promotion of the national guidelines.7, 9, 10 Halterman et al10 found that in the years 1991 to 1994, 26% of children
with moderate-to-severe asthma reported using inhaled controller therapy in
the previous month. However, unlike these authors we found significant sex
differences in controller use. In addition, although preschool-age children
were less likely to be initiated on controller therapy, similarly to the findings
of Goodman et al,9 we found that adolescents
are less likely to use them regularly. The varied nature of the practice types
in the MCOs we studied, as well as their geographic diversity, suggests that
our results can be extrapolated more generally. Our findings indicate that
current systems of care for children with asthma lead to less than ideal asthma
management, and that the passage of time is not substantially altering this
situation. The sharp discrepancy seen among frequent ß-agonist users
between any dispensing of a controller and more regular use suggests that
attention needs to be focused more on the barriers to long-term use of controllers
by patients and families than on simply getting clinicians to prescribe "a
controller" for chronic asthma.
A number of factors may explain why children with more frequent symptoms
are apparently not receiving adequate asthma therapy. That there are many
children who have both frequent dispensings of bronchodilators and one dispensing
of controller, but do not receive refills of controllers, suggests that limited
patient adherence plays a major role.20, 21
Adherence with treatment declines in adolescence, and most deaths from childhood
asthma occur in adolescents.15 External influences
can have major effects; in a recent study,22
26% of adolescent inhaler users were not allowed to carry their medication
on their person while at school. It is also possible that less frequent physician
visits could explain the lower regular use of controllers in adolescents.
Adolescents initiate visits to physicians at much lower rates than do younger
children.23 It is also possible that physicians
do not, or are unable to, schedule routine and timely follow-up visits to
monitor the clinical situation for children started on controller medication,
as is recommended in the guidelines.4 Hence,
children, especially adolescents, may be using prescriptions with long-term
refills or requesting telephone refills without physicians' complete awareness
of their frequent ß-agonist use. More effective systems of monitoring
and of providing feedback to physicians of patterns of patient drug usage
are possible methods for improving this situation.
Concern about adverse effects may also reduce the ICS use, both from
a reluctance of physicians to prescribe ICSs and of families to continue using
them.24 Such concerns do not explain the concomitant
underuse of alternative medications such as cromolyn. An alternative explanation
why children may be dispensed 1 or 2 controllers per year is that physicians
may be using them to manage exacerbations. This management strategy is unproven
and would not accord with current guideline recommendations.25
Most cases of asthma in children are identified by the age of 5 years.26 Therapy for preschool-age children differs from that
for older children in several ways. Overall, controller use is lower in children
aged 3 to 5 years, adjusted for ß-agonist use, and this age difference
is greater in those needing less frequent bronchodilator treatment. Cromolyn
is used more often in younger children, a pattern seen with more frequent ß-agonist
use as well as in children needing less bronchodilator treatment. There are
several likely reasons for these differences. Delivery methods for ICSs currently
available in the United States may limit their use in this younger age group.27 Although the use of metered-dose inhalers with close-fitting
masks has been shown to be effective28, 29
and some experts would recommend them as the first-choice device,29 the lack of a corticosteroid formulation for use
via nebulizer in the United States may lead clinicians to favor cromolyn in
preschool-age children. The severity of asthma may be underestimated in younger
children.24, 30 Less frequent ß-agonist
use (1-3 dispensings per year) may indicate intermittent asthma in which controllers
are not indicated, and intermittent disease may be more common in preschool-age
than older children. Finally, concern over the potential long-term adverse
effects of ICSs may cause physicians to use cromolyn in young children. However,
the majority of preschool-age children dispensed 6 or more ß-agonists
were not using cromolyn regularly. In young children ( 5 years old) with
frequent symptoms, low use of ICSs is not being compensated by increased use
of cromolyn.
Although the relative differences in use of controllers between boys
and girls are small, this discrepancy would still lead to large absolute numbers
of inadequately treated girls with asthma. Several reasons can be postulated
as to why we found differences in the frequency of controller dispensing in
girls and boys. Dysanaptic growth of airways and lung parenchyma may show
sex differences, leading boys to have smaller airways for the same lung volume
than do girls, with consequently more frequent airway obstruction.31 Symptoms of wheezing are more likely to be treated
as asthma than symptoms such as persistent nocturnal cough,32
and there may be sex differences in types of asthma symptoms. Kühni and
Sennhauser33 found that in Swiss children,
for all asthma symptoms except wheeze, approximately twice as many boys as
girls received bronchodilator treatment. Boys have also been reported to be
more likely than girls to receive medication, regardless of the frequency
of wheezing.34 Psychosocial influences may
be important. Physicians, parents, and children may have different perceptions
of symptoms and different attitudes toward treatment of girls and boys. For
instance, exercise limitation in boys may be perceived as a problem that requires
treatment more often than it does in girls. In this regard, it is interesting
to note that a previous study based on self-report did not show sex differences
in use of controller therapy.10 The large sex
difference for repeated controller use among preschool-age children dispensed
6 or more ß-agonists, a group for whom symptoms are likely to be a significant
problem that will attract the attention of parents and physicians, suggests
a role for psychosocial factors. Quality improvement efforts may need to focus
on sex differences in asthma management, and further work is needed to explore
this area.
The strength of our study lies in the diverse practice-type settings
of the MCOs studied, as well as their geographic spread. However, this study
has a number of limitations. The absence of individual clinical data limits
the conclusions that can be drawn regarding the appropriateness of medication
regimens for many children in our study, as we lack an independent definition
of severity. However, in the group of children with frequent ß-agonist
dispensings, we can be confident that the large proportion not regularly using
controllers represents less than ideal use of asthma therapy. We used medication
dispensing as a surrogate for actual medication consumption. The effect of
this may be varied, as some children will not use the dispensed medication,
while others will obtain medicine from nonpharmacy sources, such as physician
samples or family members. It is likely that our estimates of the amount of
medication for regular use is an overestimation of the actual duration of
use, as some medication will not be used and some will be used at higher doses
than 2 to 3 puffs a day but for shorter periods. The advantage of this method
over patient self-report is that recall bias and the tendency for people to
give socially desirable responses are limited. The reliability of the automated
data in capturing the dispensing of medications has been demonstrated previously
in these systems.35 The proportion of children
receiving no prescription therapy for asthma was similar to that found by
Buchner et al7 using similar methods of claims
data analysis in MCOs. No adjustment was made for dosage of controller medication,
nor was any weighting performed to adjust for potency of different inhaled
steroids. The effect of this is probably minimal as the use of fluticasone
or budesonide is very small, and the recommended doses of other ICSs are very
similar. A lack of data on factors such as race, smoking, and detailed socioeconomic
status measures is also a limitation of the study's conclusions. The cross-sectional
design and the absence of data from other periods make it difficult to discern
temporal trends in dispensing patterns.
In the diverse managed care settings we studied, most children with
frequent symptoms, as judged by their use of bronchodilators, have received
some pharmacotherapy to combat airway inflammation. However, at any age the
majority of children with frequent need for bronchodilators are not using
sufficient controller medication to be considered "regular" users of preventive
therapy, as recommended in national guidelines. Adolescents are at particular
risk for suboptimal asthma management. Clinicians also need to be aware of
potential sex differences in asthma management. Organizations and clinicians
need to focus on strategies that encourage greater medication adherence with
regular maintenance asthma therapy among patients and families.
AUTHOR INFORMATION
Accepted for publication December 12, 2000.
Funding for this study was provided by Pediatric Asthma Care–PORT
II, grant HS08368; the Agency for Healthcare Research and Quality; the National
Heart, Lung, and Blood Institute; and Rhône Poulenc Rhorer Pharmaceuticals.
Dr Adams is a recipient of the Thoracic Society of Australia and New Zealand/Allen
and Hanbury's Respiratory Research Fellowship. Dr Fuhlbrigge is supported
by a Mentored Clinical Scientist Development Award (1 KO8 HL03919-01) from
the National Heart, Lung, and Blood Institute.
From the Channing Laboratory, Brigham and Women's Hospital, Harvard
Medical School, Boston, Mass (Drs Adams, Fuhlbrigge, and S. T. Weiss and Mr
Livingston); Center for Healthcare Studies, Northwestern University, Chicago,
Ill (Dr K. B. Weiss); Department of Ambulatory Care and Prevention, Harvard
Medical School and Harvard Pilgrim Health Care, Boston (Dr Finkelstein); and
Center for Health Studies, Group Health Cooperative of Puget Sound and the
Department of Pediatrics, University of Washington, Seattle (Dr Lozano).
Corresponding author and reprints: Anne Fuhlbrigge, MD, MS, Channing
Laboratory, Brigham and Women's Hospital, 181 Longwood Ave, Boston, MA 02115
(e-mail: anne.fuhlbrigge{at}channing.harvard.edu).
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