Children at Risk of
Receiving Sub-Standard
Asthma Care
Alex Y. Chen, MD, MSHS
Jose J. Escarce, MD, PhD
Ronald Ferdman, MD, MEd
Introduction
zAsthma is:
– the most prevalent chronic disease in
children.
– a treatable and manageable chronic
condition.
– a condition with large disparity in
health outcomes.
Background
Objective
z Guidelines
for the Diagnosis and
Management of Asthma (NHLBI/NAEPP)
Severity
Symptoms Relief Med Controller
< 2 x / wk
Bronchodilator
none
Mild Persistent
> 2 x / wk
Bronchodilator
daily low dose
Mod. Persistent
> 1x / day
Bronchodilator
daily med dose
Severe Persistent
cont./freq
Bronchodilator
high dose +
systemic
Mild Intermittent
z To
examine socioeconomic and
demographic factors associated
with sub-standard asthma care in
children.
Data
z Medical
Expenditure Panel Survey
(MEPS) 1996-2000
– Household Full Year Consolidated File
– Medical Conditions File
– Event Linkage File
– Prescribed Medicines File
Method
z MEPS
was not intended as a clinical
data source
– Frequency of symptoms and severity of
illness cannot be directly assessed.
z We
developed a set of criteria based on
visit and prescription medication usage
patterns to indirectly assess the
frequency of asthma symptoms.
1
Overview
Visit and Rx usage Criteria
1) > 400 therapeutic doses (appox. 4
metered-dosed inhalers) of short-acting
bronchodilator (SAB) Rx filled per year.
2) > 2 emergency department visits per year.
3) > 1 inpatient hospital stay(s) per year.
4) > 2 courses of systemic corticosteroids per
year.
z Study
Population: a nationally representative
sample of children 5- 17 years of age with asthma.
z Unit
of Analysis: person- year.
z Analyses: Multivariate logistic regression.
– Dependent Variable: sub-standard asthma care
– Independent Variables: age, gender, race, family
income, insurance, health status, and maternal
education.
Selected Odds Ratios and PP-values
Likelihood of SubSub-standard Care
Results
Percent of children Among each group,
positive for each
% of children with
criteria
sub-standard care
Criteria
1)
2)
> 400 doses
SAB
> 2 ED visits
21.4 %
52.8 %
5.9 %
70.0 %
3)
> 1 inpatient
4.3 %
62.9 %
4)
> 2 systemic
steroid courses
6.3 %
47.2 %
Category Variable
Race
Black
Hispanic
White
Mat. Edu. HS deg. +
HS or less
Insurance Private
Public
Uninsured
Conclusions
zA
considerable percentage of children in the
U.S. with asthma received sub-standard
care, based on visit and medication usage
patterns.
z Children of mothers with lower education
were at increased risk for sub-standard care.
z Insurance coverage (both public and
private) appeared to reduce the risk for substandard asthma care.
O.R.
2.07
1.40
1.00
0.32
1.00
0.55
0.23
1.00
-P value
0.16
0.45
Ref. Grp.
0.02
Ref. Grp.
0.45
0.06
Ref. Grp.
Limitations
z Our
approach was not sensitive enough to
identify all children receiving sub-standard
asthma care.
z Our
study was unable to determine if the
sub-standard care occurred at the provider
level, patient level, or system level.
2
Policy Implications
Thank you !!
z Promote
the enrollment of children into
SCHIP and/or Medicaid.
z Devote additional resources to less educated
parents.
z Educate providers and promote guidelinerecommended care.
z Health plans may be able to monitor the
quality of asthma care with pharmacy and
visit data.
3