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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.
ABSTRACT
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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.
INTRODUCTION
ASTHMA PREVALENCE and morbidity remain high among children of low-income
families compared with their more advantaged peers.1-3
Although reasons for such differences are complex, a broad literature suggests
that poor children, especially of racial and ethnic minorities, lack access
to appropriate primary health care services1, 4-5
and may not receive the range of available, effective treatment modalities
recommended in national guidelines.6 Such guidelines
focus on asthma as a chronic, inflammatory condition. Recommended pharmacological
management includes use of anti-inflammatory agents as controller medications
for all children with persistent asthma, defined as those with symptoms occurring
more frequently than 2 days per week or with nighttime symptoms occurring
more than twice per month. Anti-inflammatory agents, especially inhaled corticosteroids,
have been shown to decrease symptoms7-8
and hospitalizations.9-11
Routine checkups for asthma and the use of written, structured action plans
are believed to help implement these guidelines and improve patient adherence
to prescribed treatments.6
Previous studies12-18
have documented underuse of controller medications (inhaled corticosteroids
and mast-cell stabilizers) in general and particularly in low-income populations.19-20 The Asthma Care Quality Assessment
(ACQA) Study is an investigation of patterns of asthma-related health care
for Medicaid-enrolled patients in 5 managed health care plans. Given the high
levels of asthma morbidity in low-income children, we must understand better
the reasons for underuse of controller medications and what might alter these
treatment patterns. Therefore, as part of this study, we sought to identify
demographic factors and processes of care that are associated with underuse
of controller medications among children with evidence of persistent asthma.
PARTICIPANTS AND METHODS
The data used for this analysis were collected during the baseline telephone
survey for the ACQA Study. The following 5 large, nonprofit health care plans
participated: Harvard Vanguard Medical Associates (an affiliate of Harvard
Pilgrim Health Care) in Massachusetts, Kaiser Permanente in Northern California,
Group Health Cooperative in Washington State, Partnership Healthplan of California,
and Neighborhood Health Plan in Massachusetts. The former three are group-model
health maintenance organizations (HMOs) in which a large provider group contracts
exclusively or almost exclusively with the health insurance plan. Medicaid
members are in the minority in these health plans, in which most members are
commercially insured. In contrast, the latter two are mixed-model Medicaid
managed care organizations (MCOs) that contract with a variety of provider
groups, including community health centers.
Automated registration and claims files of each health care plan were
used to identify Medicaid-insured children and adolescents aged 2 to 16 years
who met at least 1 of the following criteria: an asthma-related ambulatory,
emergency department visit or hospitalization in the past 12 months or medication
use suggestive of a diagnosis of asthma. The medication use criteria included
at least 2 dispensings of a ß-agonist or at least 1 dispensing of a controller
medication (inhaled corticosteroid, cromolyn sodium, or nedocromil sodium).
The study was approved by the institutional review board at each of
the study centers. An initial contact letter included elements of informed
consent and offered a $10 incentive for participation. Research assistants
conducted telephone interviews in English or Spanish from a single site from
February through October, 1999. During the initial telephone call, parents
confirmed the diagnosis of asthma in their child and provided verbal consent
to participate. In August and September 1999, an identical version of the
survey was mailed to families not yet reached by telephone. The interview
included demographic items such as patient age and race and parental age and
education. Access to health care was assessed by whether parents reported
the child to have a primary care physician. Items reflecting processes of
care received in the previous 6 months included receiving a written care plan,
having an asthma-related follow-up visit (defined as going to a doctor's office
or clinic for asthma follow-up care or checkups), and having seen an asthma
specialist. Current asthma burden was assessed using the Physical Function
Score of the American Academy of Pediatrics (AAP) Child Health Status Assessment
instrument for asthma.21 Medication use was
determined by asking parents to list prescription asthma medications they
had at home, and for each, how often they had been used by their child in
the past 2 weeks (daily, 3-6 d/wk, 1-2 d/wk, or not at all).
Current symptoms were determined by asking about the number of days
during the past 14 with any asthma symptom (including cough, wheeze, shortness
of breath, or limited activity). We categorized patients as having persistent
asthma if they were symptomatic on 5 or more days during the past 14, corresponding
to the definition of persistent asthma (>2 symptom-days per week) in the National
Asthma Education and Prevention Program (NAEPP) guideline.6
We also included patients using daily controller medications in the persistent
asthma category, even if they did not meet the symptom threshold, under the
assumption that, without medication, they would have experienced symptoms.
Children with symptoms less frequent than 5 days during the past 14 (and no
daily controller use) were considered to have intermittent asthma.
According to the NAEPP guideline, children with persistent symptoms
should receive daily controller medication (including inhaled corticosteroids
or mast-cell stabilizers). We considered patients to be underusers if no use
(nonusers) or less than daily use of such medications was reported. We did
not include leukotriene antagonists, long-acting ß-agonists, or theophylline
in our definition of controllers, as rates of use of these medications were
low during the study period. Our bivariate analyses compared underusers of
controller medications with those who reported daily use among patients with
evidence of persistent asthma (Figure 1).
Patients for whom only intermittent symptoms were reported and who were not
daily users of controller medications were excluded from these analyses.
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Division of respondents by symptom burden and self-reported medication
frequency. Data are given as number (percentage) of patients. AI indicates
anti-inflammatory agent, including inhaled corticosteroids, cromolyn sodium,
and nedocromil sodium. The patients in the shaded areas were excluded from
analyses.
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We used the general approach of Aday and Andersen22
to build logistic regression models to examine associations of demographic
and process-of-care variables with underuse (vs daily use) among symptomatic
children. We began by including patient age, MCO, and AAP Physical Function
Score (a proxy for asthma symptom severity) based on the a priori judgment
that these were potential confounders for which adjustment is usually made
in asthma research. We tested patient race, parental education, and family
income in a stepwise fashion and retained predictors that were significant
at P<.10. We then tested having a primary care
physician as a variable representing general access to health care and again
retained it if the results were significant. Finally, we tested whether reports
of the following specific processes of care in the past 6 months were associated
with underuse: receiving a written action plan, having had an asthma-related
follow-up visit, and having seen an asthma specialist. Odds ratios (ORs) and
95% confidence intervals (CIs) are reported for the final model only. We performed
all analyses using SAS Version 8 (SAS Institute, Cary, NC). To evaluate the
predictors of controller medication underuse in a subgroup of extremely symptomatic
children (at least 10 symptom-days during the past 14), we applied the final
model to predict underuse in these patients.
RESULTS
We identified a sample of 4094 children with asthma based on health
plan data. After excluding 603 (15%) who were no longer plan members and another
141 (3%) who returned postcards declining participation, we attempted contact
of 3350 parents of eligible patients with asthma and completed contact with
2568. Of these, 628 were deemed ineligible because they did not have asthma
(n = 430), had a sibling in the study (n = 66), had a language barrier (n
= 65), were no longer enrolled in the health plan (n = 54), or for other reasons
(n = 13). A total of 1663 consented to participate in the interview for a
response rate of 66%, based on the method of the Council of American Survey
Research Organizations, which subtracts the estimated number of ineligible
nonrespondents from the denominator.23 An additional
15 respondents were excluded from this analysis because they did not answer
the primary symptom frequency question, for a final sample of 1648. Table 1 gives the demographic characteristics
of the sample. Among the identified patients with asthma, we found a predominance
of boys (58% vs 42%). The sample included representation of white (31%), black
(38%), and Latino (19%) patients; the remaining 12% were categorized as "other."
The median educational level of parents was a completed high school education.
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Table 1. Sample Characteristics of 1648 Survey Respondents*
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Figure 1 shows the division
of respondents by symptom burden and self-reported frequency of controller
use. We categorized a total of 1083 children as having persistent asthma for
this analysis. Of these, 980 patients (90%) reported at least 5 symptom-days
during the past 14, with 651 (66%) of these reporting at least 10 symptom-days
during the past 14. An additional 103 (10%) reported daily use of controller
medication with intermittent or no symptoms. Among children with persistent
asthma, 293 (27%) reported daily use of controller medication as recommended
by the NAEPP guideline.6 The remaining 790
(73%) were designated controller medication underusers, with 529 (49%) reporting
no controller medication use and 261 (24%) reporting use less frequently than
every day. The other 565 patients (shaded categories in Figure 1) reported fewer than 5 symptom-days during the past 14
and were not daily users of controller medication. These patients were excluded
from the main comparisons of this study, which sought to identify predictors
of daily controller medication use among the 1083 patients who met criteria
for persistent asthma.
Table 2 presents the association
of demographic factors and process-of-care variables with controller medication
underuse. Underuse varied with age, and was more common in children younger
than 4 years (79%) and in adolescents (81%) compared with school-aged children
(P<.01). Parents with more than a high school
education were less likely than those with a high school degree or less to
have a child who underused controller medications (67% vs 78%; P<.001). Race was also a significant predictor, with parents of
black (75%) and Latino (79%) patients reporting higher rates of underuse than
parents of white patients (69%) (P<.001). Self-reported
family income was not associated with differential underuse.
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Table 2. Association of Demographic Factors and Process-of-Care Measures
With Controller Medication Underuse Among Medicaid-Insured Children With Persistent
Asthma*
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Variables that reflect access to medical care and processes of care
were also associated with differential rates of underuse. Patients who reported
having no primary care physician had higher rates of underuse (88%) compared
with those who did (71%) (P<.001). Children who
had not seen an asthma specialist were also more likely to report underuse
(77% vs 55%; P<.001). Having been given a written
care plan was associated with lower likelihood of underuse of controller medications
(60% vs 79%; P<.001). A similar result was seen
for having had a follow-up appointment in the past 6 months (68% vs 85%; P<.001).
The final multivariate model simultaneously adjusted for age, MCO, AAP
Physical Function Score, and demographic and process-of-care variables (Table 3). Race remained a significant predictor
of underuse, with an adjusted OR of 1.7 (95% CI, 1.2-2.4) for black race and
2.2 (95% CI, 1.3-3.8) for Latino race. Parental education beyond high school
also remained protective against underuse (OR, 0.6; 95% CI, 0.4-0.8). Patients
with a primary care physician were less likely to report underuse (OR, 0.4;
95% CI, 0.2-0.8). The magnitude of the independent effects of having a written
care 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 a specialist (OR, 0.5; 95% CI, 0.4-0.7) were similar.
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Table 3. Associations of Selected Demographic and Process-of-Care Measures
With Controller Medication Underuse Among Medicaid-Insured Patients With Persistent
Asthma*
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We used the threshold from the NAEPP guidelines for defining persistent
symptoms (>2 symptom-days per week). We also tested whether the same variables
would be associated with underuse among children who were extremely symptomatic
( 10 symptom-days during the past 14). In this analysis, we found virtually
identical point estimates and CIs for each of the variables of interest.
As a secondary analysis, we examined whether correlates of controller
underuse differed for patients reporting no use compared with those reporting
partial use (1-6 d/wk). Among nonusers, ORs for demographic variables were
almost identical to those in the primary analysis. Associations with having
a primary care physician (OR, 0.4; 95% CI, 0.2-0.8), receiving an action plan
(OR, 0.4; 95% CI, 0.3-0.6), having had a follow-up visit (OR, 0.5; 95% CI,
0.3-0.7), and having seen a specialist (OR, 0.4; 95% CI, 0.3-0.7) were significant
and similar to those found in the primary analysis. In models predicting partial
controller use, the results were also similar to those of the primary analysis,
although the ORs for black (OR, 1.5; 95% CI, 1.0-2.4) and Latino (OR, 1.8;
95% CI, 1.0-3.5) race no longer reached statistical significance at a level
of P<.05. Having a primary care physician (OR,
0.9; 95% CI, 0.4-2.1) was not associated with partial controller use, but
the remaining 3 process-of-care measures, ie, receiving an action plan (OR,
0.7; 95% CI, 0.5-1.0), having had a follow-up visit (OR, 0.7; 95% CI, 0.4-0.9),
and having seen an asthma specialist (OR, 0.7; 95% CI, 0.5-1.1), showed effects
in the same direction, although of decreased magnitude.
COMMENT
These data show substantial underuse of anti-inflammatory agents by
Medicaid-insured children with asthma in 5 geographically dispersed health
care plans. We found 72.9% percent of children with persistent asthma were
underusers of these medications; approximately two thirds of these patients
reported no use of anti-inflammatory agents. We examined demographic factors
and process-of-care variables. Associations with the latter are particularly
important, since they may point toward effective strategies to improve health
care. Minority race was associated with underuse, and education beyond high
school was protective. All 3 of the process-of-care measures examined were
associated with lower risk for underuse, even when entered into a single model
that controlled for current symptom burden and all significant demographic
predictors.
Underuse of controller medications in the presence of persistent symptoms
is concerning and is not limited to Medicaid-insured populations. Goodman
et al24 found that only 29% of children in
an HMO who were prescribed an anti-inflammatory agent had more than 2 canisters
dispensed during a 1-year period. A study from the Pediatric Asthma Care PORT
(Patient Outcomes Research Team) reported that 69% of those with 3 dispensings
of a ß-agonists had a controller medication dispensed, and only 48% had
repeated dispensings (3).17 In surveys
of MCO members, Diette et al16 reported that
64% of adult users of inhaled corticosteroids reported underdosing (use <5
d/wk). This group more recently reported similar data for children in MCOs,
and found only 55% of patients with moderate and severe asthma reported daily
use of long-term controller medications.18
Early work by Bosco et al19 showed low rates
of use of asthma medication and inhaled steroids among Medicaid-insured individuals
in particular. More recent studies in Medicaid-insured and inner-city populations
support and extend this finding.5, 20, 25
For example, Eggleston et al20 reported that
of patients with 8 or more symptom-days in the past month, only 12% were taking
anti-inflammatory agents.
The underlying reasons for underuse of controller agents remain unclear.
A recent comparison of Medicaid-insured and commercially insured children
in an HMO showed differences in dispensing rates of controller agents, but
similar rates of prescriptions written.26 This
finding raises the possibility that reported underuse may be the result of
patient adherence to prescribed regimens as well as underprescribing by clinicians.
Leickly et al27 identified concern about adverse
effects and doubts about the usefulness of medications as common in the inner-city
sample they interviewed. Focus groups of parents of low-income children with
asthma confirm that health beliefs and misunderstanding about preventive asthma
medications are important factors in adherence.28
The present study, based on parental report without confirmation by means
of medical record review, provides an estimate of what is actually being received
by patients but cannot separate the effects of inadequate prescribing of controller
medications from patient adherence to prescribed preventive regimens. Even
among children with asthma in a study monitoring use of inhaled medication,
parent report has been shown to overestimate, by up to 50%, what is actually
received.29
The finding that race and parental education are associated with medication
underuse, even among insured low-income populations, is disturbing, but is
consistent with the findings of other studies on access to prescription medications.30 In asthma, patient race or ethnicity has been associated
with increased prevalence31-34
and morbidity5, 35 and lower quality
of health care.36-37 Nonwhite
race has been associated specifically with suboptimal medication regimens
in adults.16 A separate analysis of racial
and ethnic variation in the processes and outcomes of asthma care is currently
underway as part of the ACQA Study.38
A structured, proactive approach to caring for children with asthma
has been outlined by the NAEPP guidelines.6
This stepwise approach recommends regular asthma checkups to assess current
asthma symptoms and to optimize preventive medication regimens. These steps
are intended to ensure symptom control and that children are prescribed the
lowest effective dose of controller medications. An observational study in
a single HMO has suggested a benefit of written plans.39
The present study, in a Medicaid-insured population, also suggests that written
plans and follow-up visits are associated with more appropriate medication
use. Of course, in this cross-sectional study, we are not able to discern
whether these processes of care are responsible for improved medication use
or are markers for other health care processes or unmeasured patient attributes.
However, given that these techniques are tested, inexpensive methods to standardize
medical care for chronic disease,40 this study
supports attempts to increase the use of such asthma care plans by primary
care providers for low-income children.
Our finding that having seen an asthma specialist is associated with
higher rates of use of anti-inflammatory agents is consistent with the results
of studies in non–Medicaid-insured populations, such as those found
in a large HMO.13 Those patients who seek or
are referred to specialists may be more motivated or have more severe disease.
However, studies suggest that specialists prescribe more guideline-adherent
regimens, independent of disease severity,13, 41
and may have systems that allow more effective patient education.42 The finding that specialty care is associated with
more appropriate medication use among low-income children reinforces the need
for access to specialists, or equivalent systems of care, for Medicaid-insured
and other low-income children.
The strengths of this study include its relatively large sample of low-income
children, with an overall response rate of 66%. The number of collaborating
health plans ensures geographic and health care delivery system diversity.
Previous studies using the administrative data of health plans only have been
criticized for inferring asthma symptom levels by counting pharmacy dispensings
of ß-agonist medications. It is not clear whether automated pharmacy
data or patient reports should be considered the gold standard for estimation
of medications received. With automated data, it is impossible to know the
frequency of use of these medications at any point in time. In this study,
we have concurrent reports of symptoms, ß-agonist use, and controller
use. However, by relying on parental report, we may still overestimate medication
use by these children.29 By repeating the analysis
on a subgroup of extremely symptomatic children, we have shown that the associations
of underuse with demographic and process-of-care variables are similar, even
in patients with moderate to severe asthma.
Although Medicaid managed care programs are expanding throughout the
country, these data may not be representative of all Medicaid enrollees. However,
we have no reason to believe that the effects of demographic and process-of-care
indicators would differ for Medicaid-insured patients in fee-for-service systems.
We excluded from analysis patients with intermittent symptoms who were not
taking their controller medication daily. Patients who had a controller medication
prescribed may have had a diagnosis of persistent asthma; however, since these
patients experienced good asthma control (during the 14 days before the interview),
we did not feel justified in categorizing them as underusers. Finally, a cross-sectional
study cannot establish a causal relationship between, for example, the use
of written care plans and decreased underuse of controller medications. We
report associations with these process-of-care measures but rely on supporting
literature to conclude that institution of written action plans and asthma
checkup visits among those who do not now receive them will actually decrease
underuse of controller agents among symptomatic children.
Even with these caveats, the fact that we are able to show independent
effects of demographic factors and specific processes of care in this population
of low-income children is important. We have identified straightforward actions
that providers and parents can take that may enhance the quality of health
care received by low-income children. Given the well-documented effectiveness
of controller medications in reducing morbidity due to asthma, adoption of
these measures may help to reduce some of the disproportionate burden of asthma
on low-income children. Managed care plans serving Medicaid members should
continue to experiment with structured ways of improving the quality of care
provided to their enrollees.
AUTHOR INFORMATION
Accepted for publication February 7, 2002.
The ACQA Project was supported by grant HS09935 from the Agency for
Healthcare Research and Quality (Rockville, Md), by the American Associations
of Health Plans Foundation (Washington, DC), and by the Maternal and Child
Health Bureau (Rockville).
We thank the core study team, including Nancy Jensvold, MPH, Angela
Capra, MA, and Felicia Chi, MPH, for their intellectual contributions and
their hard work. This study would not have been possible without the support
of senior leaders at each of the health care plans who provided access and
guidance. We also thank Bernard Friedman, PhD, at the Agency for Healthcare
Research and Quality for his thoughtful input and support of this work. We
are grateful to the hundreds of parents and children who shared their experiences
and opinions in the interviews for this study.
Corresponding author and reprints: Jonathan A. Finkelstein, MD, MPH,
Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard
Pilgrim Health Care, 133 Brookline Ave, 6th Floor, Boston, MA 02215 (e-mail: Jonathan_Finkelstein{at}harvardpilgrim.org).
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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