Evaluation of asthma prescription measures and health system performance based on emergency department utilization

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.

Short-acting bronchodilators purchase as a marker for asthma control

BACKGROUND

Administrative data has been used to quantify the amount of medication use in order to identify at-risk asthma patients. In our previous study we used short-acting beta-agonists (SABA) inhalers as a marker for asthma control.

METHODS

We further analyzed patient data from the SABA inhalers study in which asthma control was classified by GINA guidelines, physician assessment and the patients overall estimation. We identified all short-acting bronchodilator purchases (SABA and anticholinergic inhalers and solutions) in the year prior to administering the questionnaire relating to asthma control, and compared inhaled and systemic steroid use.

RESULTS

Of 241 asthma patients, 83 completed questionnaires. Using the GINA guidelines criteria, 26 were symptom controlled, 46 were partially controlled and 11 were uncontrolled. Using patients' overall impression of their asthma control, mean annual short-acting bronchodilator purchases were significantly higher in the partially controlled and uncontrolled patients (10 and 8.9 respectively) than in the controlled patients (2, p = 0.005). Most asthma patients purchase less than half of the controller medications prescribed to them.

CONCLUSION

When using administrative data, 3 or more -of all types of short-acting bronchodilator purchases in one year should alert the physician to evaluate asthma control and purchase alerts should notify both physicians and patients when controller consumption is low.

Patient Outcomes, Health Care Resource Use, and Costs Associated with High Versus Low HEDIS Asthma Medication Ratio

BACKGROUND

The Healthcare Effectiveness Data and Information Set (HEDIS) quality measures for asthma include the asthma medication ratio (AMR) as a marker of quality of care for patients with asthma. Few data are available to describe the association between health care use and costs in patients with high versus low AMR.

OBJECTIVE

To characterize health care use and costs associated with high versus low AMR in patients participating in commercial health plans.

METHODS

In a commercial claims database, this study retrospectively identified patients aged 5 to 64 years on December 31, 2011, who met the HEDIS definition of asthma in the premeasurement year (January 1, 2010-December 31, 2010) and the measurement year (January 1, 2011-December 31, 2011). Each patient was classified as having either high or low AMR based on the HEDIS definition. AMR was calculated as the ratio of controller to total asthma medications; high AMR was defined as ≥ 0.5. Annual per-patient health care use and costs were compared in patients with high versus low AMR using (a) multivariable linear regression models to estimate mean annual number of office visits, oral corticosteroids (OCS) bursts (≤ 15-day supply), and costs and (b) negative binomial models to estimate mean annual hospitalization and emergency department (ED) visits. All estimates were adjusted for age, sex, region, and Charlson Comorbidity Index score to control for differences between patients with high versus low AMR.

RESULTS

Patients were identified with high (30,575) and low (6,479) AMR. An average patient with high AMR had more all-cause office visits (14.1 vs. 11.0; P < 0.001), fewer all-cause hospitalizations (0.109 vs. 0.215; P < 0.001), fewer all-cause ED visits (0.321 vs. 0.768; P < 0.001), and fewer OCS bursts (0.83 vs. 1.33; P < 0.001) than an average patient with low AMR. An average patient with high AMR had fewer asthma-related hospitalizations (0.024 vs. 0.088; P < 0.001) and ED visits (0.060 vs. 0.304; P < 0.001) than an average patient with low AMR. Numbers of asthma-related annual office visits were similar between the high and low AMR groups (high 2.2 vs. low 2.2; not significant). The rate of poor asthma control events (≥ 6 short-acting beta-agonist dispensing events or ≥ 2 OCS bursts, asthma-related ED visits, or hospitalizations) was greater in patients with low AMR than in patients with high AMR (74.3% vs. 26.9%). An average patient with high AMR had lower annual nonmedication costs than an average patient with low AMR ($5,733 vs. $6,295; P = 0.011). Similar trends emerged for asthma-related costs. A patient with high AMR had higher average total annual health care costs than a patient with low AMR ($9,811 vs. $8,398; P < 0.001). These increased costs primarily resulted from increased medication costs for patients with high versus low AMR ($4,077 vs. $2,103; P < 0.001).

CONCLUSIONS

Although patients with high AMR had more office visits and higher medication (which resulted in higher overall health care) costs, their care was marked by fewer OCS bursts (indicating fewer instances of poor asthma control), fewer ED visits, and fewer hospitalizations and lower non-medication costs than those patients with low AMR. These findings support the use of AMR as a care quality measure for patients with persistent asthma.

DISCLOSURES

This study was funded by Genentech. Luskin has received consulting and lecture fees, research and travel support, and payment for developing educational presentations from Genentech and has received lecture fees from Merck. Raimundo and Solari are employees of Genentech. Antonova was employed by Genentech at the time of this study. Broder and Chang are employees of Partnership for Health Analytic Research, which received funding from Genentech to conduct this research. Study concept and design were contributed by all authors. Broder and Chang conducted analyses. All authors interpreted the data. Antonova wrote the manuscript with assistance from the other authors. All authors participated in manuscript review and revisions.

A population-based study of adults who frequently visit the emergency department for acute asthma. California and Florida, 2009-2010

RATIONALE

Little is known about adults who frequently visit the emergency department (ED) for acute asthma, or the economic impact of this ED use.

OBJECTIVES

To examine the proportion and patient characteristics of adult patients with multiple ED visits for acute asthma and the associated hospital charges.

METHODS

We analyzed population-based data from the Healthcare Cost and Utilization Project state ED and inpatient databases for two large states (California and Florida) between 2009 and 2010. We focused on adult asthma patients with asthma-related ED visits. Hospital charge data were available only for Florida.

MEASUREMENTS AND MAIN RESULTS

The final cohort comprised 86,224 unique patients with 131,907 asthma-related ED visits. Within 1 year of the first ED visit, 26% (95% confidence interval, 25-26%) of patients had multiple (two or more) ED visits. In a multivariable model adjusting for comorbidities, significant predictors of multiple ED visits were black race, Hispanic ethnicity, and low socioeconomic status (all P < 0.05). In multivariate modeling in finer categories of ED visit number, increasingly stronger associations were found for higher numbers of asthma-related ED visits. Total charges were $346 million in Florida; patients with multiple ED visits accounted for 57% (95% confidence interval, 51-62%) of total charges.

CONCLUSIONS

In this population-based cohort, 26% of patients had multiple asthma-related ED visits within 1 year. These patients were more likely to be black, Hispanic, and of lower socioeconomic status; they accounted for 57% of asthma-related hospital charges in Florida. To improve population health and to control asthma-related health care spending, we believe it is imperative to identify and assist adults with frequent asthma-related ED visits.

Effectiveness of an asthma quality improvement program designed for maintenance of certification

OBJECTIVE

Pediatricians are required to perform quality improvement for board recertification. We developed an asthma project within the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, designed to meet recertification requirements and improve asthma care.

METHODS

The program was based on the learning collaborative model. We developed practice-based registries of children 5 to 17 years of age with persistent asthma and helped physicians improve processes of asthma care through education, data feedback, and sharing of best practices.

RESULTS

Fifty-six physicians participated in 3 cohorts; 594 patients were included in the project. In all cohorts, improvements occurred in the use of asthma action plans (62.4%-76.8% cohort 1, 50.6%-88.4% cohort 2, 53.0%-79.6% cohort 3) and Asthma Control Tests (4.6%-55.2% cohort 1, 9.0%-67.8% cohort 2, 15.2%-61.4% cohort 3). Less consistent improvements were observed in seasonal influenza vaccines, controller medications, and asthma follow-up visits. The proportion of patients experiencing ≥1 asthma exacerbation within the year declined in all 3 cohorts (37.8%-19.9%, P = .0002 cohort 1; 27.8%-20.7%, P = .1 cohort 2; 36.6%-26.9%, P = .1 cohort 3). For each cohort, asthma exacerbations declined to a greater extent than those of a comparison group.

CONCLUSIONS

This asthma quality improvement project designed for maintenance of certification improved processes of care among patients with persistent asthma. The learning collaborative approach may be a useful model for other board-recertification quality improvement projects but requires a substantial investment of organizational time and staff.

Emergency department visits for acute asthma by adults who ran out of their inhaled medications

This study was designed to determine the percentage of asthma-related emergency department (ED) visits made by patients who recently ran out of their inhaled short-acting beta-agonists or inhaled corticosteroids and to characterize this understudied patient population. A secondary analysis was performed of data from four ED-based multicenter studies of acute asthma during 1996-1998 (n = 64 EDs). In each study, consecutive adult patients, aged 18-54 years, with acute asthma underwent a structured interview that assessed running out of inhaled medications. The analytic cohort comprised 1095 adults. Overall, 324 patients (30%; 95% confidence interval [CI], 27-32%) ran out of either of their inhaled beta-agonists or inhaled corticosteroids during the week before their index ED visit; 311 (28%; 95% CI, 26-31%) ran out of inhaled beta-agonists per se. Among a subset of 518 patients on inhaled corticosteroids, 55 patients (11%; 95% CI, 8-14%) ran out of inhaled corticosteroids. In the multivariable model, predictors of running out of an asthma medication were male sex, non-Hispanic black race, Hispanic ethnicity, no insurance, lower household income, and use of EDs as the preferred source of asthma prescriptions (all p < 0.05). Among patients who ran out of medications, 49% (95% CI, 43-55%) ran out of inhaled beta-agonists and 72% (95% CI, 58-84%) ran out of inhaled corticosteroids, before onset of their acute asthma symptoms. In 1095 adult ED patients with acute asthma, we found that 30% ran out of their inhaled asthma medications before the ED visit. Asthma patients who ran out of medications had sociodemographic characteristics that may help with identification of preventable ED visits. Multifaceted strategies needed to ensure optimal use of inhaled medications are warranted.

Asthma medication ratio predicts emergency department visits and hospitalizations in children with asthma

OBJECTIVE

To determine if the asthma medication ratio predicts subsequent emergency department (ED) visits and hospital admissions in children.

DESIGN

Retrospective cohort with two year pairs.

SETTING/PARTICIPANTS

2007-2009 South Carolina Medicaid recipients with persistent asthma age 2-18.

MAIN EXPOSURE

Controller-to-total asthma medication ratios were calculated for each patient in 2007 and 2008. Ratios range from 0-1 (1 = ideal, 0 = no controller).

OUTCOME MEASURES

2008 and 2009 asthma related ED visits, hospitalizations, and a combined outcome of ED visit or hospitalization in the subsequent 3, 6, and 12 month time periods.

RESULTS

19,512 patients were included. Mean age 8.9 years, 58% male, and 55% black. The ratio significantly predicted ED visits and hospitalizations over subsequent 3, 6, and 12 month time periods. The cut-point that maximized the ability to predict visits ranged from 0.4-0.6. A cutpoint of 0.5 was used in the final models. After controlling for age, race, gender, and rurality, patients with a ratio <0.5 were significantly more likely to have a subsequent emergent healthcare visit (OR 1.5-2.0). The ratio retained its predictive ability in both year-pairs for all three outcome variables, in all three time periods, with the exception of the 2008 ratio not predicting 2009 3-month and 6-month hospitalizations.

CONCLUSIONS

The asthma medication ratio is a significant predictor of ED visits and hospitalizations in children. Using a cutoff of <0.5 to signal at-risk patients may be an effective way for populations who would benefit from increased use of controller medications to reduce future emergent asthma visits. CPT only copyright XXXX-2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. See attached CMS CPT 2013 end user license.

Patterns of health care utilization for asthma treatment in adults with substance use disorders

OBJECTIVES

: National goals for improving asthma outcomes include decreasing emergency room utilization and increasing adherence to outpatient treatment guidelines. Few studies have examined the impact of substance use disorders on asthma treatment. The objective of this study was to describe correlations between substance use disorders and patterns of healthcare utilization for asthma care.

METHODS

: We performed a retrospective analysis of 1999 Medicaid claims for adults with asthma from 5 states. Adjusted odds of receiving asthma treatment in outpatient, inpatient, and emergency settings were calculated for patients with substance use disorder (SUD).

RESULTS

: Consistent patterns emerge demonstrating significantly lower odds of utilization of outpatient services for asthma in patients with SUD. A trend toward increased utilization of acute care resources was observed, with odds of emergency care for asthma significantly increased in New Jersey (odds ratio [OR], 1.14; 95% confidence interval [CI], 1-1.31) and Georgia (OR, 1.24; 95% CI, 1.04-1.48), and odds of inpatient care for asthma significantly increased in Georgia (OR, 1.42; 95% CI, 1.03-1.95).

CONCLUSIONS

: Substance use disorders are associated with decreased odds of receiving outpatient care and equivalent or increased odds of receiving emergency and inpatient care for asthma. Consequently, outpatient-based strategies to improve asthma care may have a very limited impact for this population. Identifying asthma patients with SUD in acute care settings and enhancing the care they receive in these settings may be necessary to improve adherence to treatment guidelines and decrease utilization in this population.

High use of health services in patients with suboptimal asthma drug regimens: a population-based assessment in British Columbia, Canada

BACKGROUND

Despite numerous clinical guidelines on asthma management, patients often receive suboptimal drug therapy. This study identified patients who received suboptimal regimens according to the National Heart, Lung and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma in a complete population (residents of British Columbia, Canada) and determined the association between patients' regimens and utilization of healthcare services.

METHODS

A total of 65,345 asthma patients were identified using provincial health service utilization data (including all respiratory-related prescription medication dispensings, physician and hospital visits) for the 2009 fiscal year. Patient-specific regimens of inhaled short-acting bronchodilators (SABA) with or without inhaled corticosteroids (ICS) were categorized as optimal or suboptimal. Logistic regression models were used to determine the association between regimen optimality and health service utilization, adjusted for socioeconomic status, prior year hospital and emergency department (ED) visits for asthma.

RESULTS

Patients with suboptimal regimens had significantly greater risk of using health services than patients with optimal regimens of SABA and/or ICS. In particular, adolescents with suboptimal regimens were the most likely to have hospital admissions (odds ratio (OR) 3.8; 95% confidence interval (CI) 1.8-7.8), visit the ED (OR 2.2; 95% CI 1.6-3.1) and be high users of family physician services (OR 5.7; 95% CI 4.0-8.1) compared with patients in other age groups.

CONCLUSIONS

Suboptimal regimens are associated with significantly high usage of health services. Identifying patients with suboptimal regimens and improving their medication management in accordance with asthma clinical guidelines are likely to result in lower health service utilization.

Uptake and effectiveness of a community pharmacy intervention programme to improve asthma management

WHAT IS KNOWN AND OBJECTIVE

Pharmacists frequently see patients with asthma in the community who have suboptimal management. This study aimed to compare the uptake and effectiveness of pharmacist-initiated mailed and face-to-face interventions for patients whose asthma may not be well managed.

METHODS

Seventy-one community pharmacies in South Australia, Tasmania and Victoria (Australia) installed a software application that data-mined dispensing records, generating a list of patients who had received six or more asthma reliever inhalers in the preceding 12 months. The pharmacists were randomized, by pharmacy, to perform either a mailed or face-to-face intervention, whereby these patients received educational material and a referral to their general practitioner (GP) for an asthma management review. Matching patients from each pharmacy were also randomly assigned to a control group for 'usual care'.

RESULTS AND DISCUSSION

A total of 1483 patients were identified and grouped as follows: 510 (34·4%) mailed intervention, 480 (32·4%) face-to-face intervention and 493 (33·2%) controls. Significantly fewer face-to-face interventions were offered than mailed interventions (66·6% vs. 89·4%, respectively; χ(2) = 64·2, P < 0·0001). There were significant improvements in the preventer-to-reliever ratio after the intervention period (P < 0·0001) in each group. In a per-protocol analysis, the magnitude of improvement in the face-to-face intervention group was greater than in the mailed intervention group. The reverse was true in an intention-to-treat analysis. The improvement in the P : R ratios was mainly due to significant decreases in reliever usage.

WHAT IS NEW AND CONCLUSION

Community pharmacy dispensing records can effectively identify patients with suboptimal asthma management, who can then be referred to their GP for review. Time constraints in busy pharmacies may limit the uptake and effectiveness of face-to-face interventions in the 'real world' setting, making mailed interventions an attractive option.

Correlation of care process measures with childhood asthma exacerbations

OBJECTIVE

We sought to define processes of pediatric asthma care identifiable through administrative data that correlate with asthma exacerbations for use in quality improvement.

METHODS

Commercially insured children aged 5 to 17 years from the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, with persistent asthma in 2008, 2009, or 2010 were identified. The correlations of various process measures with asthma exacerbations, defined as hospitalizations or emergency department visits for asthma or outpatient visits for asthma with an oral steroid prescription, were analyzed by using logistic regression.

RESULTS

Significant correlations were found between filling 0 vs ≥ 1 controller medications in all years (relative risk [RR] 3.35, 2.11, and 2.71 in 2008, 2009, and 2010, respectively) although only 4% of subjects overall filled no controller medications. The asthma medication ratio (controller prescriptions divided by total asthma prescriptions) was also associated with exacerbations, with the lowest 2 quartiles having a lower risk compared with the highest in all years (RR 2.27, 2.45, and 2.39 for the lowest; RR 2.10, 2.02, and 2.65 for the second quartile in 2008, 2009, and 2010, respectively).

CONCLUSIONS

Filling 0 vs ≥ 1 controllers and the asthma medication ratio correlated with asthma exacerbations. Although both might serve as quality improvement metrics for pediatric asthma, we favor the asthma medication ratio because it applies to a broader range of children with asthma and better reflects the recommended clinical approach for children with persistent asthma.

Patient-Centered Care and Emergency Department Utilization

Increased emergency department (ED) overcrowding has renewed interest in identifying remedies for unnecessary ED utilization. One potential remedy receiving more attention is patient-centered care. Relatively little is known, however, about how patient-centered care might decrease ED utilizatiosn. This study examined two mediating processes by which four dimensions of patient-centered care may affect patients’ reported ED visits. Cross-sectional path analysis of 8,140 chronically ill patients found that patients reporting higher levels of patient-centered care were less likely to have experienced problems of care coordination, and in turn were associated with decreased likelihood of having delayed care and fewer ED visits. These findings suggest that understanding how care is delivered, and not simply whether it is available or provided, is an important consideration in understanding ED utilization. Our findings suggest that fostering more fair and respectful relationships between patients and providers may be a particularly important way of reducing ED utilization.

Comparison of instrumental variable analysis using a new instrument with risk adjustment methods to reduce confounding by indication

Confounding by indication is a vexing problem, especially in evaluating treatment effects using observational data, since treatment decisions are often related to disease severity, prognosis, and frailty. To compare the ability of the instrumental variable (IV) approach with a new instrument based on the local-area practice style and risk adjustment methods, including conventional multivariate regression and propensity score adjustment, to reduce confounding by indication, the authors investigated the effects of long-term control (LTC) therapy on the occurrence of acute asthma exacerbation events among children and young adults with incident and uncontrolled persistent asthma, using Iowa Medicaid claims files from 1997-1999. Established evidence from clinical trials has demonstrated the protective benefits of LTC therapy for persistent asthma. Among patients identified (n = 4,275), those with higher asthma severity at baseline were more likely to receive LTC therapy. The multivariate regression and propensity score adjustment methods suggested that LTC therapy had no effect on the occurrence of acute exacerbation events. Estimates from the new IV approach showed that LTC therapy significantly decreased the occurrence of acute exacerbation events, which is consistent with established clinical evidence. The authors discuss how to interpret estimates from the risk adjustment and IV methods when the treatment effect is heterogeneous.

Asthma and the achievement gap among urban minority youth

OBJECTIVES

To outline the prevalence and disparities of asthma among school-aged urban minority youth, causal pathways through which poorly controlled asthma adversely affects academic achievement, and proven or promising approaches for schools to address these problems.

METHODS

Literature review.

RESULTS

Asthma is the most common chronic disease affecting youth in the United States; almost 10 million youth under 18 (14%) have received a diagnosis and 6.8 million (9%) have active asthma. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs. 8.8%), as were average annual estimates of asthma attacks (8.4% vs. 5.8%). Urban minority youth have highly elevated prevalence of poorly controlled asthma as evidenced by overuse of emergency departments and under-use of efficacious medications. Poorly controlled asthma has functional consequences on cognition, connectedness with school, and absenteeism. Exemplary asthma programs include management and support systems, school health and mental health services, asthma education, healthy school environments, physical education and activity, and coordination of school, family, and community efforts.

CONCLUSIONS

Asthma and, more importantly, poorly controlled asthma are highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement through its effects on cognition, school connectedness, and absenteeism, and effective practices are available for schools to address this problem. To reduce the adverse effects of poorly controlled asthma on learning, a multifaceted approach to asthma control and prevention in which schools can and must play a central role is essential.

The role of income in reducing racial and ethnic disparities in emergency room and urgent care center visits for asthma-United States, 2001-2009

OBJECTIVE

To examine racial/ethnic disparities and associated factors in asthma-related emergency room (ER) and urgent care center (UCC) visits among US adults and determine whether disparities vary across increasing income strata.

METHODS

We analyzed data from 238,678 adult respondents from the 2001 to 2009 National Health Interview Survey and calculated the weighted annual prevalence of an ER/UCC visit for persons with current asthma. We used logistic regression to calculate adjusted odds ratios (AORs) for asthma-related ER/UCC visits by race/ethnicity and income, adjusting for demographics, socioeconomic, and other health-related factors.

RESULTS

The average annual prevalence of asthma-related ER/UCC visits among adults with current asthma was highest for Puerto Ricans (24.8%, 95% confidence interval [CI]: 20.3-29.9) followed by non-Hispanic American Indian/Alaskan Natives (22.1%, 95% CI: 14.4-32.4), non-Hispanic blacks (20.4%, 95% CI: 18.5-22.4), other Hispanics (17.3%, 95% CI: 15.0-19.9), Asians (11.0%, 95% CI: 7.8-15.4), and non-Hispanic whites (10.1%, 95% CI: 9.4-10.9). Puerto Ricans (AOR: 2.01; 95% CI: 1.54-2.62), non-Hispanic blacks (AOR: 1.72; 95% CI: 1.46-2.03), and other Hispanics (AOR: 1.55; 95% CI: 1.25-1.92) with current asthma had significantly higher odds of an asthma-related ER/UCC visit than non-Hispanic whites. Lower socioeconomic status, obesity, and serious psychological distress were also associated with higher odds of asthma-related ER/UCC visits. Puerto Ricans with the lowest income (AOR: 3.52; 95% CI: 2.27-5.47), non-Hispanic American Indian/Alaskan Natives with the highest income (AOR: 5.71; 95% CI: 1.48-22.13), and non-Hispanic blacks in every income stratum had significantly higher odds of asthma-related ER/UCC visits compared to non-Hispanic whites in the highest income stratum.

CONCLUSIONS

Racial/ethnic disparities in asthma-related ER/UCC visits persist after accounting for income and other socioeconomic factors. Further research is needed to identify modifiable risk factors directly associated to race/ethnicity to decrease the asthma burden on minority populations.

Improving asthma outcomes in large populations

This article summarizes our experience using administrative, survey, and telephone information to define asthma severity, impairment, risk, and quality of care in our large Kaiser Permanente population. Our data suggest that the 2-year Healthcare Effectiveness Data and Information Set definition of persistent asthma is a good surrogate for survey-defined persistent asthma, and thus it would be reasonable to direct asthma population management and quality-of-care assessments at patients with Healthcare Effectiveness Data and Information Set-defined persistent asthma for 2 years in a row. For population management, the numbers of short-acting β-agonist (SABA) canisters dispensed and validated tools on mail or telephone surveys have been used to assess asthma impairment. Algorithms based on pharmacy data (SABA canister and oral corticosteroid dispensings and prior emergency hospital care) have been used to assess the risk domain of asthma control. The asthma medication ratio (controllers divided by controllers plus SABAs) has been shown to be related to improved outcomes and is recommended as an asthma quality-of-care marker. It is hoped that outreach to patients and providers based on these indicators will improve asthma outcomes in patients cared for in individual practices, as well as in large health plans.

The sustainability of a community pharmacy intervention to improve the quality use of asthma medication

WHAT IS KNOWN AND OBJECTIVE

A previously published asthma intervention used a software application to data mine pharmacy dispensing records and generate a list of patients with potentially suboptimal management of their asthma; in particular, a high rate of provision of reliever medication. These patients were sent educational material from their community pharmacists and advised to seek a review of their asthma management from their general practitioner. The intervention resulted in a 3-fold improvement in the ratio of dispensed preventer medication (inhaled corticosteroids) to reliever medication (short-acting beta-2 agonists). This follow-up study aimed to determine the long-term effects of the intervention programme on the preventer-to-reliever (P:R) ratio.

METHODS

The same data mining software was modified so that it could re-identify patients who were originally targeted for the intervention. Community pharmacists who participated in the previous intervention installed the modified version of the software. The dispensing data were then de-identified, encrypted and transferred via the Internet to a secure server. The follow-up dispensing data for all patients were compared with their pre- and post-intervention data collected originally.

RESULTS AND DISCUSSION

Of the 1551 patients who were included in the original study, 718 (46·3%) were eligible to be included in the follow-up study. The improved P:R ratio was sustained for at least 12 months following the intervention (P < 0·01). The sustained increase in the P:R ratio was attributed to significant decreases in the average daily usage of reliever medication (P < 0·0001).

WHAT IS NEW AND CONCLUSION

The follow-up study demonstrated a sustained improvement in the ratio of dispensed preventer medication to reliever medication for asthma. The intervention has the potential to show long-lasting and widespread improvements in asthma management, improved health outcomes for patients, and ultimately, a reduced burden on the health system.

Relationship between presence of a reported medical home and emergency department use among children with asthma

This study examined data from the 2005-2006 National Survey of Children with Special Health Care Needs to assess the relationship among children with asthma between a reported medical home and emergency department (ED) use. The authors used 21 questions to measure 6 medical home components: personal doctor/nurse, family-centered, compassionate, culturally effective and comprehensive care, and effective care coordination. Weighted zero-inflated Poisson regression analyses assessed the independent effects of having a medical home on annual number of child ED visits while controlling for child and parental characteristics, and the differential likelihood of securing a medical home. Nearly half (49.9%) of asthmatic children had a medical home. Receiving primary care in a medical home was associated with fewer ED visits (incidence rate ratio = 0.93; 95% confidence interval = 0.89-0.97). A medical home in which physicians and parents share responsibility for ensuring that children have access to needed services may improve child and family outcomes for children with asthma.

Continuity of prescribers of short-acting beta agonists among children with asthma

OBJECTIVE

To determine whether short-acting beta-agonist (SABA) prescriber continuity was associated with emergency department visits among children with asthma.

STUDY DESIGN

An analysis of Michigan Medicaid administrative claims (2004-2005) for children ages 5 to 18 with asthma. Logistic regression models assessed the effect of SABA prescriber continuity (the number and site of prescribers) on emergency department visits, controlling for demographics, historical (2004) asthma use and SABA prescription frequency (2-5 low; > or = 6 high).

RESULTS

Most children had one SABA prescriber (62%); 13% had multiple prescribers in the same practice as the primary care provider and 25% had multiple prescribers in different practices. Children with multiple prescribers in different practices had increased odds of an emergency department visit compared with those with 1 prescriber, among those with high SABA prescription frequency (AOR: 2.7, 95% CI: 1.9, 3.9), as well as those with low prescription frequency (AOR: 1.7, 95% CI: 1.3, 2.2).

CONCLUSIONS

Children with discontinuity of SABA prescribers have an increased risk of asthma emergency department visits, irrespective of their SABA prescription frequency. Primary care providers may have difficulty identifying patients at high risk with asthma solely on the basis of SABAs prescribed within their own practices.

Emergency room visit: a red-flag indicator for poor diabetes care

AIM

To determine the association between emergency room (ER) admission and quality of diabetes care in the community.

METHODS

In a nested case-control study of patients with Type 2 diabetes mellitus (DM) within a large health maintenance organization (HMO) in Israel, 919 patients who were admitted to one of West Jerusalem's ERs between 1 May and 30 June 2004 were compared with 1952 control subjects not admitted. Data on study covariates were retrieved from the HMO's computerized database and a subset of the study population was interviewed. Logistic regressions were conducted to estimate the odds ratios of being admitted according to different measures of quality of care, controlling for socio-demographic variables, co-morbidities and type of DM treatment.

RESULTS

The main indices of quality of primary care that were inversely associated with visiting an ER during the study period included performance of a cholesterol test in the year prior to the index date [adjusted odds ratio (OR) 0.23, 95% confidence interval (CI) 0.19-0.29, P < 0.001], performance of glycated haemoglobin test (OR 0.26, 95% CI 0.24-0.29, P < 0.001), visiting an ophthalmologist (OR 0.47, 95% CI 0.32-0.68, P = 0.001), and recommendations to stop smoking (OR 0.10, 95% CI 0.05-0.21, P < 0.001).

CONCLUSIONS

Admission to the ER can be used as an indicator for poor quality of diabetes care. There is an association between ER admission and poor quality of diabetes care.

Comparative evaluation of two asthma care quality measures among Medicaid beneficiaries

BACKGROUND

The relative performance of asthma care quality measures has not been evaluated in Medicaid populations.

METHODS

Using complete claims and pharmaceutical data for 19,076 patients with persistent asthma (based on Health Effectiveness and Data Information Set criteria) in five Medicaid populations, we compared the following two measures of asthma care quality: filling prescriptions for controller asthma medications within 1 year and the ratio of controller medication to the total number of asthma medication prescriptions filled within 1 year. We calculated whether meeting each quality measure was associated with decreased odds of emergency department (ED) treatment episodes. We then compared the odds ratios, receiver operating characteristic (ROC) curves, and deviances between models, using each measure to predict ED utilization in Medicaid populations.

RESULTS

Although meeting each measure was associated with lower odds of ED utilization, this decrease was larger if the controller asthma medication measure was met rather than the ratio measure. Additionally, models using the controller medication measure had greater areas under the ROC curve and smaller deviances than models using the ratio measure.

CONCLUSIONS

Both administrative measures of asthma care quality were associated with lower odds of ED utilization. The controller medication measure of asthma care quality may be better than the ratio measure in relation to emergency asthma care utilization by Medicaid beneficiaries.

Quality of care for children hospitalized with asthma

OBJECTIVES

The goals were (1) to identify evidence-based clinical process measures that are appropriate, feasible, and reliable for assessing the quality of inpatient asthma care for children and (2) to evaluate provider compliance with these measures.

METHODS

Key asthma quality measures were identified by using a modified Rand appropriateness method, combining a literature review of asthma care evidence with a consensus panel. The feasibility and reliability of obtaining these measures were determined through manual chart review. Provider compliance with these measures was evaluated through retrospective manual chart review of data for 252 children between 2 and 17 years of age who were admitted to a tertiary care children's hospital in 2005 because of asthma exacerbations.

RESULTS

Nine appropriate, feasible, reliable, clinical process measures of inpatient asthma care were identified. Provider compliance with these measures was as follows: acute asthma severity assessment at admission, 39%; use of systemic corticosteroid therapy, 98%; use of oral (not intravenous) systemic corticosteroid therapy, 87%; use of ipratropium bromide restricted to <24 hours after admission, 71%; use of albuterol delivered with a metered-dose inhaler (not nebulizer) for children >5 years of age, 20%; documented chronic asthma severity assessment, 22%; parental participation in an asthma education class, 33%; written asthma action plan, 5%; scheduled follow-up appointment with the primary care provider at discharge, 22%.

CONCLUSIONS

Nine appropriate, feasible, reliable, clinical process measures of inpatient asthma care were identified. Provider compliance across these measures was highly variable but generally low. Our study highlights opportunities for improvement in the provision of asthma care for hospitalized children. Future studies are needed to confirm these findings in other inpatient settings.

Improved overall trends but persistent racial disparities in emergency department visits for acute asthma, 1993-2005

BACKGROUND

Emergency department (ED) visits for acute asthma provide an important marker of morbidity.

OBJECTIVE

To describe the epidemiology of ED visits for acute asthma.

METHODS

We obtained data from the National Hospital Ambulatory Medical Care Survey, 1993 to 2005, and used the primary diagnosis code for asthma (493) to identify cases. We calculated national estimates by using assigned patient visit weights and national rates per 1000 US population with demographic-specific population data from the US Census Bureau.

RESULTS

From 1993 to 2005, there were approximately 23,800,000 asthma visits, representing 1.8% of all ED visits, or an overall rate of 6.7 visits per 1000 US population. The national visit rate rose between 1993 and 1998 (P(trend) = .05), but was stable (or possibly decreasing) from 1998 to 2005 (P(trend) = .07). Although rates for white subjects decreased by 25% from 1998 to 2005 (P(trend) = .02), the rates for black subjects remained constant (P(trend) = .80). The overall asthma-related ED visit rate was highest among the following groups: age <10 years (13), women (7.2), black subjects (19), Hispanic subjects (7.1), and subjects in the Northeast (9.2). ED administration of inhaled anticholinergic agents increased 20-fold and systemic corticosteroids increased 2-fold from 1993 to 2005 (P(trend) = .02 and .03, respectively), whereas inhaled beta-agonist and inhaled corticosteroid administration was stable (P(trend) = .09 and .34, respectively).

CONCLUSION

Although asthma-related ED visit rates showed a significant upward trend from 1993 to 1998, our results support the emerging view that the asthma epidemic may have reached a plateau. Nevertheless, the higher visit rates observed among specific demographic groups and widening disparities, particularly among black subjects, remain problematic and warrant further investigation.

Asthma-related medication use among children in the United States

BACKGROUND

Asthma is one of the most common chronic conditions in children and has a major impact on health care use and quality of life. The Best Pharmaceuticals for Children Act mandates the federal government to sponsor pediatric studies of drugs approved for use in the United States but lacking evaluation in the pediatric population and lacking interest of commercial sponsors. As input into the drug selection and prioritization process, information is needed on the percentage of children who receive asthma-related medications.

OBJECTIVE

To estimate the percentage of children who receive asthma-related medications.

METHODS

Retrospective analysis of outpatient medical and drug claims from members of commercial health care insurance plans enrolled any time from January 1, 2004, through December 31, 2005. The study population included 4,259,103 children throughout the United States aged birth through 17 years.

RESULTS

Fifteen percent of all children were dispensed an asthma-related medication. Among 218,943 children with an asthma diagnosis, 188,286 (86%) had a dispensed asthma-related medication at any time during the 2-year study period. Among children without any asthma diagnoses, 398,880 (10%) had a dispensed medication. Fifty-nine percent of children with an asthma diagnosis were dispensed an anti-inflammatory medication within 90 days after a claim with a diagnosis of asthma.

CONCLUSIONS

Asthma-related medications are dispensed to a large percentage of the pediatric population, including many who do not have claims with asthma diagnoses listed. Data on the pharmacokinetics and safety of these drugs in children are largely unknown and difficult to obtain. Clinical studies that use new tools and approaches are needed to resolve this information gap.

Health plan notification and feedback to providers is associated with increased filling of preventer medications for children with asthma enrolled in Medicaid

OBJECTIVE

To test the hypothesis that children enrolled in Medicaid managed care health plans that provide asthma-specific communication to providers would be more likely to have adequate asthma medication filling.

STUDY DESIGN

We conducted a historical cohort study of 4498 children (2-17 years old) with moderate-severe asthma in Washington State and Tennessee Medicaid managed care programs from 2000 to 2002. Interviews with health plans were conducted to identify communication strategies health plans used to improve asthma care by providers in the plan. The main outcome measure was guideline-recommended filling of asthma preventer medications.

RESULTS

Children in plans that provided specific feedback to providers about asthma quality and notified providers when children had an asthma-related event had the highest mean days plus or minus SE of filling in the 365-day follow-up period (164.6 +/- 13 days) compared with children in plans with neither (135.3 +/- 10.8 days; P < .05). In children with the greatest asthma severity, enrollment in a plan with both features was associated with 27.1 additional days of filling (95% CI, 0.7-53.4 days) during the follow-up period.

CONCLUSION

Health plan communication to providers was associated with increased preventer filling in children with moderate-severe asthma in 2 state Medicaid programs.

Impact of the Singapore National Asthma Program (SNAP) on Preventor-Reliever Prescription Ratio in Polyclinics

Introduction: The Singapore National Asthma Program (SNAP) was launched in 2001 to address the high burden of asthma in Singapore. One component of the SNAP was directed at improving asthma control in the community by promoting preventive treatment with inhaled corticosteroids. This paper describes the program on prescription patterns of preventor and reliever medication for asthma in the polyclinics. Materials and Methods: We monitored the prescription pattern for asthma as the preventor-reliever (PR) drug ratio. The PR ratio was employed both as a positive feedback tool and as a key performance indicator (KPI) for the program. Individual clinics were encouraged to implement locally relevant and effective initiatives to increase the KPI and facilitate this process. The different methods included chronic care models, multidisciplinary teams, enhanced primary care clinics, pre-counselling screening, decision support tools, self-management support, a patient information system and community education. Results: In the course of the program, the case load for asthma in the polyclinics increased by 31%. During the same period, the average PR ratio increased significantly from 0.68 to 1.80 (P <0.001). Conclusions: A simple audit and positive feedback program based on PR ratios, accompanied by sustained local quality improvement cycles has been associated with a significant shift in the drug treatment of asthma away from episodic quick relief medication towards long-term daily preventive treatment with inhaled steroids in polyclinics. Key words: Education, Inhaled steroids

Use of the health plan employer data and information set for measuring and improving the quality of asthma care

OBJECTIVES

To discuss the Health Plan Employer Data and Information Set (HEDIS) criteria for measuring performance in asthma care and to review new strategies to improve the quality of asthma care.

DATA SOURCES

Expert opinion from a roundtable on National Committee for Quality Assurance HEDIS and asthma care, supplemented with a MEDLINE database search to identify articles published between January 1, 1990, and May 31, 2005, with the following keywords in the title: asthma plus HEDIS, pay for performance, incentive programs, reimbursement, or employee education.

STUDY SELECTION

Studies and review articles were selected for their relevance to measuring the quality of asthma care using HEDIS and improving care using newer trends, such as employee education and physician incentive programs.

RESULTS

Components of the HEDIS asthma measure have been found to correlate with outcomes, including risk of hospitalization and emergency department visits. However, refinements to the measure may be needed because it may misclassify a portion of patients as having persistent asthma who actually have intermittent asthma according to National Heart, Lung, and Blood Institute criteria. Physician incentive programs are increasingly being explored as a means of improving the quality of care while managing costs. Under current pay-for-performance programs, rewards are issued to providers who demonstrate high-quality care based on the HEDIS asthma measure.

CONCLUSIONS

The HEDIS asthma measure remains the most widely used performance tool for evaluating the quality of asthma care. Reimbursement models based on public reporting and pay for performance are expected to be a strong component of future health care payment systems.

Asthma medication use in school-aged children

Using data from the 1996, 1998, and 2000 Medical Expenditure Panel Survey, this study assessed controller medication use in a national representative sample of school-aged children with persistent asthma. Children 5 to 17 years of age with persistent asthma were identified in accordance with the Health Employer Data and Information Set specifications. Nonuse of controllers and excess use of relievers were common. In addition, controller medications were significantly less likely to be purchased for younger children, black and Hispanic children, and white children whose mothers had at least a college education. Efforts to improve childhood asthma management are needed, especially for those children.

The controller-to-total asthma medication ratio is associated with patient-centered as well as utilization outcomes

BACKGROUND

The ratio of controller medication to total asthma medications has been related to asthma utilization outcomes, but its relationship to patient-centered outcomes has not been explored.

METHODS

Surveys that included validated asthma quality-of-life, control, and symptom severity tools were completed by a random sample of 2,250 health maintenance organization members aged 18 to 56 years who had persistent asthma. Linked computerized pharmacy data provided dispensing information on beta-agonist canisters and asthma controller medication. The ratio was calculated as the number of controller medications dispensed during the year of the survey divided by the total number medications (ie, inhaled beta-agonist plus controller medications) dispensed. The relationships of the optimal ratio cutoff to patient-centered outcomes and to subsequent acute asthma exacerbations were determined.

RESULTS

Mean asthma quality-of-life, asthma control, and symptom severity scale scores were significantly (p < 0.0001) more favorable in patients with ratios of > or = 0.5. After adjusting for demographic characteristics, patients with ratios of > or = 0.5 were significantly less likely to have adverse results regarding asthma quality of life (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52 to 0.80), asthma control (OR, 0.62; 95% CI, 0.50 to 0.77), and symptom severity (OR, 0.53; 95% CI, 0.43 to 0.65), and were also less likely to experience subsequent asthma hospitalizations or emergency department visits (OR, 0.44; 95% CI, 0.26 to 0.74) than patients with lower ratios.

CONCLUSION

A higher controller medication/total asthma medication ratio is associated with better patient-centered asthma outcomes as well as with reduced emergency hospital utilization. This adds further support to the use of the medication ratio as an asthma quality-of-care measure.

Practice-level effects of interventions to improve asthma care in primary care settings: the Pediatric Asthma Care Patient Outcomes Research Team

OBJECTIVE

To assess the practice-level effects of (1) a physician peer leader intervention and (2) peer leaders in combination with the introduction of asthma education nurses to facilitate care improvement. And, to compare findings with previously reported patient-level outcomes of trial enrollees.

STUDY SETTING

Data were included on children 5-17 years old with asthma in 40 primary care practices, affiliated with managed health care plans enrolled in the Pediatric Asthma Care Patient Outcomes Research Team (PORT) randomized trial.

STUDY DESIGN

Primary care practices were randomly assigned to one of two care improvement arms or to usual care. Automated claims data were analyzed for 12-month periods using a repeated cross-sectional design. The primary outcome was evidence of at least one controller medication dispensed among patients with persistent asthma. Secondary outcomes included controller dispensing among all identified asthmatics, evidence of chronic controller use, and the dispensing of oral steroids. Health service utilization outcomes included numbers of ambulatory visits and hospital-based events.

PRINCIPAL FINDINGS

The proportion of children with persistent asthma prescribed controllers increased in all study arms. No effect of the interventions on the proportion receiving controllers was detected (peer leader intervention effect 0.01, 95 percent confidence interval [CI]: -0.07, 0.08; planned care intervention effect -0.03, 95 percent CI: -0.09, 0.02). A statistical trend was seen toward an increased number of oral corticosteroid bursts dispensed in intervention practices. Significant adjusted increases in ambulatory visits of 0.08-0.10 visits per child per year were seen in the first intervention year, but only a statistical trend in these outcomes persisted into the second year of follow-up. No differences in hospital-based events were detected.

CONCLUSIONS

This analysis showed a slight increase in ambulatory asthma visits as a result of asthma care improvement interventions, using automated data. The absence of detectable impact on medication use at the practice level differs from the positive intervention effect observed in patient self-reported data from trial enrollees. Analysis of automated data on nonenrollees adds information about practice-level impact of care improvement strategies. Benefits of practice-level interventions may accrue disproportionately to the subgroup of trial enrollees. The effect of such interventions may be less apparent at the level of practices or health plans.

Recent advances in the development of anti-allergic drugs

Research over the past decade has provided information concerning the onset and treatment of allergic diseases, including bronchial asthma, allergic rhinitis and atopic dermatitis. Recent studies also indicated that allergic inflammation is the basic pathophysiology of allergic diseases and is closely associated with their progression and exacerbation. Our understanding of the mechanism of allergic inflammation with regard to therapeutic agents has improved as a result of immunological and molecular biological studies. While much effort has been paid to developing a new anti-allergic drug, allergic disease has yet to be completely conquered. More extensive research will allow the development of new therapeutics to combat allergic diseases. This article provides an overview of recent advances in the development of anti-allergic drugs.

Correlation of initial emergency department pulse oximetry values in asthma severity classes (steps) with the risk of hospitalization

BACKGROUND

The oxygen saturation (OSAT) of wheezing children presenting to an emergency department has been shown to be a predictor for hospitalization. The purpose of this study is to determine if hospitalization predictive power can be increased by further stratifying this by the step severity categories (based on chronic symptoms).

METHODS

Data were collected prospectively at 6 centers over a 22-month period on 1219 pediatric patients. Asthma step severity categorization was determined by chronic symptom history. Presenting ED OSAT values, extensive clinical histories (obtained in the ED and during several telephone follow-up calls by study personnel), treatments, and disposition were recorded for each study subject.

RESULTS

The overall hospitalization rate was 15%. Hospitalization rates in severity step categories 1, 2, 3, and 4 were 13%, 16%, 13%, and 22% (P = .008), respectively. Hospitalization rates by presenting OSATs were 98% or higher (6%), 95% to 97% (12%), 93% to 94% (28%), 90% to 92% (45%), 85% to 89% (65%), and 80% to 84% (100%). From 95% to 100% OSAT values, hospitalization rates are similar between the severity groups. In the 93% to 94% OSAT group, the hospitalization rate is 43% in step category 4 patients, compared with 27%, 24%, and 13% for step categories 1, 2, and 3, respectively, but this difference was not statistically significant. At presenting OSAT values of 90% and below, the hospitalization rates are higher but did not differ significantly between the severity step groups. No recognizable trend was present to suggest that the hospitalization predictive value is increased by adding the step severity categories.

CONCLUSIONS

The presenting OSAT is the dominant initial predictor of hospitalization. The step severity categories do not appear to provide substantial additional predictive value for hospitalization.

Asthma quality-of-care markers using administrative data

STUDY OBJECTIVE

To evaluate the relationship of potential asthma quality-of-care markers to subsequent emergency hospital care.

DESIGN

Retrospective administrative database analysis.

SETTING

Managed care organization.

PATIENTS

Asthmatic patients aged 5 to 56 years of age.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Candidate quality measures included one or more or four or more controller medication canisters, a controller/total asthma medication ratio of > or = 0.3 or > or = 0.5, and the dispensing of fewer than six beta-agonist canisters in 2002. Outcome was a 2003 asthma emergency department visit or hospitalization. Multivariable analyses adjusted for age, sex, and year 2002 severity (based on utilization). In the total sample (n = 109,774), one or more controllers (odds ratio, 1.35) and four or more controllers (odds ratio, 1.98) were associated with an increased risk of emergency hospital care, whereas a controller/total asthma medication ratio of > or = 0.5 (odds ratio, 0.73) and the dispensing of fewer than six beta-agonist canisters (odds ratio 0.30) were associated with a decreased risk. After adjustment for baseline severity in the total asthma sample, the controller/total asthma medication ratio (odds ratio, 0.62 to 0.78) and beta-agonist measure (odds ratio, 0.42) were associated with decreased risk, whereas the dispensing of four or more canisters of controller medication was associated with increased risk (odds ratio, 1.33). After stratification by year 2002 beta-agonist use, all of the measures were associated with decreased risk in those who received fewer than six beta-agonist canisters, whereas all of the measures except the medication ratio of > or = 0.5 were associated with increased risk in the cohort who received six or more beta-agonist canisters.

CONCLUSION

Controller use and beta-agonist use may function as severity indicators in large populations rather than as asthma quality-of-care markers. A medication ratio of > or = 0.5 appeared to function as the best quality-of-care marker in this study.

Pediatric asthma surveillance using Medicaid claims

OBJECTIVE

The purpose of this study was to describe the prevalence of asthma among children using alternative case definitions applied to administrative claims data, and to assess year-to-year classification concordance.

METHODS

This study was a retrospective cohort analysis of 357,729 children 0-18 years using 2001-2002 Michigan Medicaid claims. Asthma cases were classified using six alternative definitions based on outpatient, emergency department, inpatient, and pharmacy claims for asthma, including the Health Plan Employer Data Information Set (HEDIS) persistent asthma criteria commonly used for assessments of asthma health care quality: at least one asthma inpatient admission or emergency department visit, four or more asthma medications events, or four asthma outpatient visits and two asthma medication events.

RESULTS

Overall, asthma prevalence varied widely between alternative case definitions, ranging from 14.9% based on claims evidence of any type of asthma utilization to 3.7% when restricted to those with four or more asthma medication dispensing events. Among cases meeting HEDIS persistent asthma criteria in 2001, 55.5% met these criteria in 2002. Those with four or more asthma medication dispensing events had the best overall classification concordance between 2001 and 2002. Utilization of asthma services and prevalence estimates were highest among children younger than 5 years old, but year-to-year classification concordance was poorest among these cases (p < 0.0001), irrespective of case definition.

CONCLUSIONS

While overall asthma prevalence may remain relatively stable from year to year, individuals may not be classified consistently as cases over time, regardless of case definition. Studies that identify asthma cases in one year and assess asthma outcomes in a subsequent year may introduce substantial bias as a result of case misclassification. Among the case definitions considered in this study, our findings suggest that this bias is minimized among cases classified using the four or more asthma medication dispensing events criterion.

Treatment patterns for pediatric asthma prior to and after emergency department events

There are 2 million asthma-related emergency department (ED) events each year in the United States. Children share a disproportional burden of these events. This study was designed to describe the treatment patterns in children in the year prior to and 2 months after an ED event. This retrospective observational study utilized the PharMetrics Integrated Outcomes Database that contains administrative claims from over 20 managed-care plans across the United States. Children aged 1-17 years with at least one ED visit for asthma during 2001 were included. Patients were required to have data available 12 months prior to and 2 months following the ED visit. We identified 5,501 pediatric asthma-related ED admissions. In the year prior to the ED event, 19.4% of children received an inhaled corticosteroid (ICS), 31.4% an oral corticosteroid (OCS), and 58.3% a short-acting beta-agonist (SABA). Overall, there were 3.7 albuterol units for every ICS unit dispensed in the 12 months prior to the event. Ninety-four percent of the children had an office visit in the year prior to the ED visit. Prescriptions dispensed for ICS and OCS increased 2.9-fold and 8.2-fold, respectively, in the month after the ED event. However, the dispensing rates for both medications reverted to near baseline by the second month after the index event. In conclusion, this study demonstrates the dependence of children with asthma on the use of rescue medications. An ED event results in only an incremental and transient increase in ICS-containing controller treatment.

Asthma economics: focusing on therapies that improve costly outcomes

PURPOSE OF REVIEW

In 1998, the economic burden of asthma was estimated to be 12.7 billion dollars. Subsequent research has focused on identifying important outcomes that reflect high resource utilization and finding therapies that improve these outcomes and decrease cost. Recent developments include an update to the National Heart, Lung, and Blood Institute (NHLBI) guidelines, new treatment strategies using combination therapy, and the development of a monoclonal antibody therapy for asthma.

RECENT FINDINGS

Two important costly outcomes are asthma-related hospitalizations and emergency department visits. Asthma-related hospitalizations started to decline in the 1990s, primarily in white Americans, but not in young African Americans. Many hospitalizations and emergency department visits are preventable, and costs were lowered by shifting management to the ambulatory care setting. Increased asthma severity and suboptimal compliance with NHLBI asthma care guidelines can contribute to the persistence of symptoms, which triggers behaviors that increase resource utilization.A recent economic analysis was one of the first well-controlled clinical trials to show that inhaled corticosteroids provide clinical benefit at modest costs. Combination therapy, particularly that containing an inhaled corticosteroid and long-acting bronchodilator in a single inhaler, potentially can reduce overall costs by improving compliance with inhaled corticosteroids. Nonpharmacologic therapies also have been shown to be cost-effective. However, a significant number of patients with asthma continue to have symptoms even while on recommended controller therapy. Omalizumab, a monoclonal antibody treatment that binds IgE, was released in the summer of 2003.

SUMMARY

Many costly asthma-related hospitalizations and emergency department visits are preventable, and chronic disease care can be shifted to the ambulatory setting. Increased asthma severity and noncompliance with NHLBI guidelines are associated with increased resource utilization. Combination therapies can assist in improving patient compliance, and omalizumab potentially offers a novel but expensive way to decrease symptoms and resource utilization.