Weight status and nonadherence to asthma maintenance therapy among children enrolled in a public drug insurance plan

Utilization and Spending With Preventive Drug Lists for Asthma Medications in High-Deductible Health Plans

Importance

High-deductible health plans with health savings accounts (HDHP-HSAs) incentivize patients to use less health care, including necessary care. Preventive drug lists (PDLs) exempt high-value medications from the deductible, reducing out-of-pocket cost sharing; the associations of PDLs with health outcomes among patients with asthma is unknown.

Objective

To evaluate the associations of a PDL for asthma medications on utilization, adverse outcomes, and patient spending for HDHP-HSA enrollees with asthma.

Design, Setting, and Participants

This case-control study used matched groups of patients with asthma before and after an insurance design change using a national commercial health insurance claims data set from 2004-2017. Participants included patients aged 4 to 64 years enrolled for 1 year in an HDHP-HSA without a PDL in which asthma medications were subject to the deductible who then transitioned to an HDHP-HSA with a PDL that included asthma medications; these patients were compared with a matched weighted sample of patients with 2 years of continuous enrollment in an HDHP-HSA without a PDL. Models controlled for patient demographics and asthma severity and were stratified by neighborhood income. Analyses were conducted from October 2020 to June 2023.

Exposures

Employer-mandated addition of a PDL that included asthma medications to an existing HDHP-HSA.

Main Outcomes and Measures

Outcomes of interest were utilization of asthma medications on the PDL (controllers and albuterol), asthma exacerbations (oral steroid bursts and asthma-related emergency department use), and out-of-pocket spending (all and asthma-specific).

Results

A total of 12 174 participants (mean [SD] age, 36.9 [16.9] years; 6848 [56.25%] female) were included in analyses. Compared with no PDL, PDLs were associated with increased rates of 30-day fills per enrollee for any controller medication (change, 0.10 [95% CI, 0.03 to 0.17] fills per enrollee; 12.9% increase) and for combination inhaled corticosteroid long-acting β2-agonist (ICS-LABA) medications (change, 0.06 [95% CI, 0.01 to 0.10] fills per enrollee; 25.4% increase), and increased proportion of days covered with ICS-LABA (6.0% [0.7% to 11.3%] of days; 15.6% increase). Gaining a PDL was associated with decreased out-of-pocket spending on asthma care (change, -$34 [95% CI, -$47 to -$21] per enrollee; 28.4% difference), but there was no significant change in asthma exacerbations and no difference in results by income.

Conclusions and Relevance

In this case-control study, reducing cost-sharing for asthma medications through a PDL was associated with increased adherence to controller medications, notably ICS-LABA medications used by patients with more severe asthma, but was not associated with improved clinical outcomes. These findings suggest that PDLs are a potential strategy to improve access and affordability of asthma care for patients in HDHP-HSAs.

Impact of Unmet Social Needs, Scarcity, and Future Discounting on Adherence to Treatment in Children With Asthma: Protocol for a Prospective Cohort Study

BACKGROUND

Asthma is one of the most prevalent chronic diseases of childhood and disproportionately affects children with lower socioeconomic status. Controller medications such as inhaled corticosteroids significantly reduce asthma exacerbations and improve symptoms. However, a large proportion of children still have poor asthma control, in part owing to suboptimal adherence. Financial barriers contribute to hindering adherence, as do behavioral factors related to low income. For example, unmet social needs for food, lodging, and childcare may create stress and worry in parents, negatively influencing medication adherence. These needs are also cognitively taxing and force families to focus on immediate needs, leading to scarcity and heightening future discounting; thus, there is the tendency to attribute greater value to the present than to the future in making decisions.

OBJECTIVE

In this project, we will investigate the relationship between unmet social needs, scarcity, and future discounting as well as their predictive power over time on medication adherence in children with asthma.

METHODS

This 12-month prospective observational cohort study will recruit 200 families of children aged 2 to 17 years at the Asthma Clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary care pediatric hospital in Montreal, Canada. The primary outcome will be adherence to controller medication, measured using the proportion of prescribed days covered during follow-up. Exploratory outcomes will include health care use. The main independent variables will be unmet social needs, scarcity, and future discounting, measured using validated instruments. These variables will be measured at recruitment as well as at 6- and 12-month follow-ups. Covariates will include sociodemographics, disease and treatment characteristics, and parental stress. Primary analysis will compare adherence to controller medication, measured using the proportion of prescribed days covered, between families with versus those without unmet social needs during the study period using multivariate linear regression.

RESULTS

The research activities of this study began in December 2021. Participant enrollment and data collection began in August 2022 and are expected to continue until September 2024.

CONCLUSIONS

This project will allow the documentation of the impact of unmet social needs, scarcity, and future discounting on adherence in children with asthma using robust metrics of adherence and validated measures of scarcity and future discounting. If the relationship between unmet social needs, behavioral factors, and adherence is supported by our findings, this will suggest the potential for novel targets for integrated social care interventions to improve adherence to controller medication and reduce risk across the life course for vulnerable children with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05278000; https://clinicaltrials.gov/ct2/show/NCT05278000.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37318.

Adherence to inhaled corticosteroids prescribed once vs twice daily in children with asthma

BACKGROUND

Suboptimal adherence to inhaled corticosteroids (ICS) is associated with poor asthma control. Adult studies suggest that simplification of ICS regimen leads to better adherence.

OBJECTIVE

We aimed to determine whether once-daily, compared with twice-daily, ICS dosing was associated with better adherence among children with asthma.

METHODS

We conducted a retrospective observational study of children with asthma prescribed with either once-daily or twice-daily ICS monotherapy between 2011 and 2019. Our primary adherence outcome was the proportion of prescribed days covered (PPDC)-that is, the number of days for which the drug was dispensed by the pharmacy divided by the number of days for which it was prescribed. The impact of once-daily vs twice-daily ICS regimen on adherence was evaluated using linear multivariable regression analysis adjusting for covariates. Secondary outcomes included the proportion of patients with greater than or equal to 75% adherence analyzed using logistic regression models.

RESULTS

A total of 232 children (61% boys; mean age of 5.8 [3.6] years) were included; 120 children were prescribed once-daily, and 112 twice-daily, ICS. The median PPDC was 66.8% for the once-daily and 57.9% for the twice-daily group (P = .03). Children prescribed once-daily ICS had a 7.2% (95% confidence interval, 1.3-13.1) greater mean PPDC compared with the twice-daily group and greater odds of having PPDC greater than or equal to 75% (71.4% vs 45.5%; odds ratio, 1.80; 95% confidence interval, 1.01-3.26).

CONCLUSION

Our findings suggest that once-daily dosing of ICS is associated with better medication adherence than twice-daily dosing. Whether the gain in adherence leads to better asthma control and health outcomes remains to be evaluated.

"He's not fat, he just has asthma": a qualitative study exploring weight management in families living with pediatric asthma

OBJECTIVE

Children and young people living with asthma have an increased risk of overweight/obesity, leading to increased severity of asthma symptoms. Weight management has been recommended to improve asthma symptoms, however, there is limited understanding of how this is experienced or how children and young people with asthma and their families wish to be supported. The aim of this study was to explore parents and children/young people's views and experiences of managing weight while living with asthma, and to identify acceptable strategies for support.Methods: A qualitative methodological approach was taken to facilitate rich understanding of families' insights into weight management while living with asthma. In-depth interviews were conducted with nine families living with pediatric asthma (n = 9 parents, 9 young people). Data were analyzed using a Framework approach.Results: Findings indicated that family engagement with weight management behaviors was primarily influenced by perceptions of risk regarding asthma outcomes and beliefs about asthma control. Families also reported weight management engagement to be influenced by perceptions of the food environment, perceptions of the exercise environment (e.g. weather, anticipated social outcomes) and the availability of weight management support. Participants sought tailored support which gave consideration to the asthma-obesity interaction. It was suggested that this would help reduce perceptions of weight stigma in consultations, thereby supporting behavioral changes.Conclusions: Individualized weight management plans that consider families concerns about asthma-related risk are needed to manage weight in children and young people living with asthma.

Controller Medication Use and Exacerbations for Children and Adults With Asthma in High-Deductible Health Plans

IMPORTANCE

High-deductible health plans (HDHPs) are increasingly common and associated with decreased medication use in some adult populations. How children are affected is less certain.

OBJECTIVE

To examine the association between HDHP enrollment and asthma controller medication use and exacerbations.

DESIGN, SETTING, AND PARTICIPANTS

For this longitudinal cohort study with a difference-in-differences design, data were obtained from a large, national, commercial (and Medicare Advantage) administrative claims database between January 1, 2002, and December 31, 2014. Children aged 4 to 17 years and adults aged 18 to 64 years with persistent asthma who switched from traditional plans to HDHPs or remained in traditional plans (control group) by employer choice during a 24-month period were identified. A coarsened exact matching technique was used to balance the groups on characteristics including employer and enrollee propensity to have HDHPs. In most HDHPs, asthma medications were exempt from the deductible and subject to copayments. Statistical analyses were conducted from August 13, 2019, to January 19, 2021.

EXPOSURE

Employer-mandated HDHP transition.

MAIN OUTCOMES AND MEASURES

Thirty-day fill rates and adherence (based on proportion of days covered [PDC]) were measured for asthma controller medications (inhaled corticosteroid [ICS], leukotriene inhibitors, and ICS long-acting β-agonists [ICS-LABAs]). Asthma exacerbations were measured by rates of oral corticosteroid bursts and asthma-related emergency department visits among controller medication users.

RESULTS

The HDHP group included 7275 children (mean [SD] age, 10.8 [3.3] years; 4402 boys [60.5%]; and 5172 non-Hispanic White children [71.1%]) and 17 614 adults (mean [SD] age, 41.1 [13.4] years; 10 464 women [59.4%]; and 12 548 non-Hispanic White adults [71.2%]). The matched control group included 45 549 children and 114 141 adults. Compared with controls, children switching to HDHPs experienced significant absolute decreases in annual 30-day fills only for ICS-LABA medications (absolute change, -0.04; 95% CI, -0.07 to -0.01). Adults switching to HDHPs did not have significant reductions in 30-day fills for any controllers. There were no statistically significant differences in PDC, oral steroid bursts, or asthma-related emergency department visits for children or adults. For the 9.9% of HDHP enrollees with health savings account-eligible HDHPs that subjected medications to the deductible, there was a significant absolute decrease in PDC for ICS-LABA compared with controls (-4.8%; 95% CI, -7.7% to -1.9%).

CONCLUSIONS AND RELEVANCE

This cohort study found that in a population where medications were exempt from the deductible for most enrollees, HDHP enrollment was associated with minimal or no reductions in controller medication use for children and adults and no change in asthma exacerbations. These findings suggest a potential benefit from exempting asthma medications from the deductible in HDHPs.

Parental Feeding, Child Eating and Physical Activity: Differences in Children Living with and without Asthma

This study aimed to establish the differences in parental attitudes toward feeding and activity, as well as child eating and activity levels, between families of children living with and without asthma. Parents of children and young people aged between 10 and 16 years living both with asthma (n = 310) and without asthma (n = 311) completed measures for parental feeding, parental attitudes toward child exercise, child eating, child activity level and asthma control. Children living with asthma had a significantly higher BMIz (BMI standardised for weight and age) score, were significantly more likely to emotionally overeat and desired to drink more than their peers without asthma. Parents of children with asthma reported greater use of food to regulate emotions, restriction of food for weight control, monitoring of child activity, pressure to exercise and control over child activity. When asthma symptoms were controlled, parental restriction of food for weight management predicted greater child BMIz scores, and higher child activity predicted lower child BMIz scores. These relationships were not found to be significant for children with inadequately controlled asthma. Differences in parental attitudes toward feeding and exercise, and child eating and exercise behaviors, between families may help to explain the increased obesity risk for children with asthma.