Health care utilization and cost among children with asthma who were enrolled in a health maintenance organization

Socioeconomic status is associated with healthcare seeking behaviour and disease burden in young adults with asthma - A nationwide cohort study

Introduction

Specialist management of asthma has been shown to associate with socioeconomic status (SES). However, little is known about the influence of SES on care burden in universal healthcare settings.

Methods

Patients aged 18–45 years using inhaled corticosteroids (ICS) were followed in national databases. Impact of asthma was investigated using negative binomial regression adjusted for age, sex, comorbidity, and GINA 2020 Step. Uncontrolled asthma was defined as >600 annual SABA puffs, ≥2 prednisolone courses and/or ≥1 hospitalization.

Results

A total of 60,534 (55% female, median age 33 (IQR 25–39)) patients were followed for 10.1 years (IQR 5.2–14.3)). Uncontrolled asthma resulted in 6.5 and 0.51 additional annual contacts to primary care and pulmonologists, respectively.

Unscheduled and primary care burden was dependent on SES, increasing with rural residence, lower education, income and receiving welfare. Differences in planned respiratory care were slight, only seen among divorced, low income- or welfare recipients. Lower SES was consistently associated with an increased utilization of SABA and prednisolone. No dose–response relationship between ICS use and SES could be identified.

Conclusion

Lower SES in asthma is a risk factor for a predominance of unscheduled care and adverse outcomes, warranting further attention to patients’ background when assessing asthma care.

Residential Proximity to Biorefinery Sources of Air Pollution and Respiratory Diseases in New York State

Understanding potential health risks associated with biofuel production is critical to sustainably combating energy insecurity and climate change. However, the specific health impacts associated with biorefinery-related emissions are not yet well characterized. We evaluated the relationship between respiratory emergency department (ED) visits (2011-2015) and residential exposure to biorefineries by comparing 15 biorefinery sites to 15 control areas across New York (NY) State. We further examined these associations by biorefinery types (e.g., corn, wood, or soybean), seasons, and lower respiratory disease subtypes. We measured biorefinery exposure using residential proximity in a cross-sectional study and estimation of biorefinery emission via AERMOD-simulated modeling. After controlling for multiple confounders, we consistently found that respiratory ED visit rates among residents living within 10 km of biorefineries were significantly higher (rate ratios (RRs) range from 1.03 to 3.64) than those in control areas across our two types of exposure indices. This relationship held across biorefinery types (higher in corn and soybean biorefineries), seasons (higher in spring and winter), air pollutant types (highest for NO₂), and respiratory subtypes (highest for emphysema). Further research is needed to confirm our findings.

Models for estimating and projecting global, regional and national prevalence and disease burden of asthma: a systematic review

Background

Statistical models are increasingly being used to estimate and project the prevalence and burden of asthma. Given substantial variations in these estimates, there is a need to critically assess the properties of these models and assess their transparency and reproducibility. We aimed to critically appraise the strengths, limitations and reproducibility of existing models for estimating and projecting the global, regional and national prevalence and burden of asthma.

Methods

We undertook a systematic review, which involved searching Medline, Embase, World Health Organization Library and Information Services (WHOLIS) and Web of Science from 1980 to 2017 for modelling studies. Two reviewers independently assessed the eligibility of studies for inclusion and then assessed their strengths, limitations and reproducibility using pre-defined quality criteria. Data were descriptively and narratively synthesised.

Results

We identified 108 eligible studies, which employed a total of 51 models: 42 models were used to derive national level estimates, two models for regional estimates, four models for global and regional estimates and three models for global, regional and national estimates. Ten models were used to estimate the prevalence of asthma, 27 models estimated the burden of asthma – including, health care service utilisation, disability-adjusted life years, mortality and direct and indirect costs of asthma – and 14 models estimated both the prevalence and burden of asthma. Logistic and linear regression models were most widely used for national estimates. Different versions of the DisMod-MR- Bayesian meta-regression models and Cause Of Death Ensemble model (CODEm) were predominantly used for global, regional and national estimates. Most models suffered from a number of methodological limitations – in particular, poor reporting, insufficient quality and lack of reproducibility.

Conclusions

Whilst global, regional and national estimates of asthma prevalence and burden continue to inform health policy and investment decisions on asthma, most models used to derive these estimates lack the required reproducibility. There is a need for better-constructed models for estimating and projecting the prevalence and disease burden of asthma and a related need for better reporting of models, and making data and code available to facilitate replication.

Applying UK real-world primary care data to predict asthma attacks in 3776 well-characterised children: a retrospective cohort study

Current understanding of risk factors for asthma attacks in children is based on studies of small but well-characterised populations or pharmaco-epidemiology studies of large but poorly characterised populations. We describe an observational study of factors linked to future asthma attacks in large number of well-characterised children. From two UK primary care databases (Clinical Practice Research Datalink and Optimum Patient Care research Database), a cohort of children was identified with asthma aged 5–12 years and where data were available for ≥2 consecutive years. In the “baseline” year, predictors included treatment step, number of attacks, blood eosinophil count, peak flow and obesity. In the “outcome” year the number of attacks was determined and related to predictors. There were 3776 children, of whom 525 (14%) had ≥1 attack in the outcome year. The odds ratio (OR) for one attack was 3.7 (95% Confidence Interval (CI) 2.9, 4.8) for children with 1 attack in the baseline year and increased to 7.7 (95% CI 5.6, 10.7) for those with ≥2 attacks, relative to no attacks. Higher treatment step, younger age, lower respiratory tract infections, reduced peak flow and eosinophil count >400/μL were also associated with small increases in OR for an asthma attack during the outcome year. In this large population, several factors were associated with a future asthma attack, but a past history of attacks was most strongly associated with future attacks. Interventions aimed at reducing the risk for asthma attacks could use primary care records to identify children at risk for asthma attacks.

A past history of asthma attacks in young children is a strong predictor for future attacks and should be factored into treatment regimes. Childhood asthma attacks take considerable toll on sufferers and their carers, yet risk factors for future attacks are unclear. David Price at the Observational and Pragmatic Research Institute in Singapore and co-workers searched UK primary care databases to find at least two years’ worth of consecutive data on children with asthma aged 5 to 12. The team analyzed data from 3,776 children. Their results showed that past attacks are the strongest predictor for future attacks; of 638 patients who experienced more than one asthma attack during the first year, 240 (38%) had attacks in the second year. Other risk factors included reduced peak flow, lower respiratory tract infections and younger age.

The Business Case for Quality: Combining Medical Literature Research with Health Plan Data to Establish Value for Nonclinical Managers

Clinical managers face a growing need to communicate the value of what they do in terms that can be interpreted by nonclinical financial managers. We have sought to link the evidence basis of current guidelines to variables that will demonstrate in more financial terms the very real benefit of treating diseases aggressively. We have developed an approach using the medical literature that is designed to describe clinical initiatives in more concrete terms as desired by senior management. This becomes specifically critical during budget time and when justification for various clinical programs is needed. The approach uses medical research from the peer-reviewed literature to estimate the economic impact of various initiatives and then combines the analysis with an organization's actual data to impute potential benefit. A sample grid for developing the analysis is attached. A comprehensive bibliography that will assist others with similar endeavors has been included. Although not as rigorous as formal methods, actuarial analyses, or health services research activities, it presents a beginning framework around which an organization can create operational estimates of initiative effectiveness.

Asthma, hay fever, and food allergy are associated with caregiver-reported speech disorders in US children

BACKGROUND

Children with asthma, hay fever, and food allergy may have several factors that increase their risk of speech disorder, including allergic inflammation, ADD/ADHD, and sleep disturbance. However, few studies have examined a relationship between asthma, allergic disease, and speech disorder. We sought to determine whether asthma, hay fever, and food allergy are associated with speech disorder in children and whether disease severity, sleep disturbance, or ADD/ADHD modified such associations.

METHODS

We analyzed cross-sectional data on 337,285 children aged 2-17 years from 19 US population-based studies, including the 1997-2013 National Health Interview Survey and the 2003/4 and 2007/8 National Survey of Children's Health.

RESULTS

In multivariate models, controlling for age, demographic factors, healthcare utilization, and history of eczema, lifetime history of asthma (odds ratio [95% confidence interval]: 1.18 [1.04-1.34], p = 0.01), and one-year history of hay fever (1.44 [1.28-1.62], p < 0.0001) and food allergy (1.35 [1.13-1.62], p = 0.001) were associated with increased odds of speech disorder. Children with current (1.37 [1.15-1.59] p = 0.0003) but not past (p = 0.06) asthma had increased risk of speech disorder. In one study that assessed caregiver-reported asthma severity, mild (1.58 [1.20-2.08], p = 0.001) and moderate (2.99 [1.54-3.41], p < 0.0001) asthma were associated with increased odds of speech disorder; however, severe asthma was associated with the highest odds of speech disorder (5.70 [2.36-13.78], p = 0.0001).

CONCLUSION

Childhood asthma, hay fever, and food allergy are associated with increased risk of speech disorder. Future prospective studies are needed to characterize the associations.

Childhood asthma exacerbations and the Arg16 β2-receptor polymorphism: A meta-analysis stratified by treatment

BACKGROUND

The Gly-to-Arg substitution at the 16 position (rs1042713) in the β2-adrenoceptor gene (ADRB2) is associated with enhanced downregulation and uncoupling of β2-receptors.

OBJECTIVES

We sought to undertake a meta-analysis to test the hypothesis that there is an interaction between the A allele of rs1042713 (Arg16 amino acid) and long-acting β-agonist (LABA) exposure for asthma exacerbations in children.

METHODS

Children with diagnosed asthma were recruited in 5 populations (BREATHE, Genes-Environments and Admixture in Latino Americans II, PACMAN, the Paediatric Asthma Gene Environment Study, and the Pharmacogenetics of Adrenal Suppression with Inhaled Steroid Study). A history of recent exacerbation and asthma treatment was determined from questionnaire data. DNA was extracted, and the Gly16Arg genotype was determined.

RESULTS

Data from 4226 children of white Northern European and Latino origin were analyzed, and the odds ratio for exacerbation increased by 1.52 (95% CI, 1.17-1.99; P = .0021) for each copy of the A allele among the 637 children treated with inhaled corticosteroids (ICSs) plus LABAs but not for treatment with ICSs alone (n = 1758) or ICSs plus leukotriene receptor antagonist (LTRAs; n = 354) or ICSs plus LABAs plus LTRAs (n = 569).

CONCLUSIONS

The use of a LABA but not an LTRA as an "add-on controller" is associated with increased risk of asthma exacerbation in children carrying 1 or 2 A alleles at rs1042713. Prospective genotype-stratified clinical trials are now required to explore the potential role of rs1042713 genotyping for personalized asthma therapy in children.

Associations of Physical Activity and Sedentary Behavior with Atopic Disease in United States Children

OBJECTIVES

To determine if eczema, asthma, and hay fever are associated with vigorous physical activity, television/video game usage, and sports participation and if sleep disturbance modifies such associations.

STUDY DESIGN

Data were analyzed from 2 cross-sectional studies including 133 107 children age 6-17 years enrolled in the 2003-2004 and 2007-2008 National Survey of Children's Health. Bivariate and multivariate survey logistic regression models were created to calculate the odds of atopic disease and atopic disease severity on vigorous physical activity, television/video game use, and sports participation.

RESULTS

In multivariate logistic regression models controlling for sociodemographic factors, lifetime history of asthma was associated with decreased odds of ≥1 days of vigorous physical activity (aOR, 0.87; 95% CI, 0.77-0.99) and decreased odds of sports participation (0.91; 95% CI, 0.84-0.99). Atopic disease accompanied by sleep disturbance had significantly higher odds of screen time and lower odds of sports participation compared with children with either atopic disease or sleep disturbance alone. Severe eczema (aOR, 0.39; 95% CI, 0.19-0.78), asthma (aOR, 0.29; 95% CI, 0.14-0.61), and hay fever (aOR, 0.48; 95% CI, 0.24-0.97) were all associated with decreased odds of ≥1 days of vigorous physical activity. Moderate (aOR, 0.76; 95% CI, 0.57-0.99) and severe eczema (aOR, 0.45; 95% CI, 0.28-0.73), severe asthma (aOR, 0.47; 95% CI, 0.25-0.89), and hay fever (aOR, 0.53; 95% CI, 0.36-0.61) were associated with decreased odds of sports participation in the past year.

CONCLUSIONS

Children with severe atopic disease, accompanied by sleep disturbance, have higher risk of sedentary behaviors.

Association of Adolescent Depressive Symptoms With Health Care Utilization and Payer-Incurred Expenditures

OBJECTIVE

Screening adolescents for depression is recommended by the US Preventive Services Task Force. We sought to evaluate the impact of positive depression screens in an adolescent population on health care utilization and costs from a payer perspective.

METHODS

We conducted depression screening among 13- to 17-year-old adolescents enrolled in a large integrated care system using the 2- and 9-item Patient Health Questionnaires (PHQ). Health care utilization and cost data were obtained from administrative records. Chi-square, Wilcoxon rank sum, and t tests were used to test for statistical differences in outcomes between adolescents on the basis of screening status.

RESULTS

Of the 4010 adolescents who completed depression screening, 3707 (92.4%) screened negative (PHQ-2 <2 or PHQ-9 <10), 186 (3.9%) screened positive for mild depression (PHQ-9 10-14), and 95 (2.4%) screened positive for moderate to severe depression (PHQ-9 ≥15). In the 12 months after screening, screen-positive adolescents were more likely than screen-negative adolescents to receive any emergency department visit or inpatient hospitalization, and they had significantly higher utilization of outpatient medical (mean ± SD, 8.3 ± 1.5 vs 3.5 ± 5.1) and mental health (3.8 ± 9.3 vs 0.7 ± 3.5) visits. Total health care system costs for screen-positive adolescents ($5083 ± $10,489) were more than twice as high as those of screen-negative adolescents ($2357 ± $7621).

CONCLUSIONS

Adolescent depressive symptoms, even when mild, are associated with increased health care utilization and costs. Only a minority of the increased costs is attributable to mental health care. Implementing depression screening and evidence-based mental health services may help to better control health care costs among screen-positive adolescents.

Perceptual accuracy of upper airway compromise in children: Clinical relevance and future directions for research

Approximately 80% of children with asthma have coexisting allergic rhinitis. The accurate recognition and assessment of asthma and rhinitis symptoms is an integral component of guideline-based treatment for both conditions. This article describes the development and preliminary evaluation of a novel paradigm for testing the accuracy of children's assessment of their upper airway (rhinitis) symptoms. This work is guided by our previous research showing the clinical efficacy of tools to evaluate children's perceptual accuracy of asthma symptoms and linking accurate asthma symptom perception to decreased asthma morbidity (Fritz G, et al., Ethnic differences in perception of lung function: A factor in pediatric asthma disparities? Am J Respir Crit Care Med 182:12-18, 2010; Klein RB, et al., The Asthma Risk Grid: Clinical interpretation of symptom perception, Allergy Asthma Proc 251-256, 2004). The pilot study tests a paradigm that allows for the examination of the correspondence of children's assessment of their upper airway functioning with actual values of upper airway flow through the use of a portable, handheld nasal peak flowmeter. Nine children with persistent asthma were evaluated over a 4-week period. The article describes the rhinitis perceptual accuracy paradigm and reviews the results of a pilot study, showing a large proportion of inaccurate rhinitis symptoms "guesses" by the sample of children with persistent asthma. Patterns of inaccuracy, rhinitis control, and asthma morbidity are also described. Directions for future work are reviewed. The development of clinical tools to evaluate children's accuracy of rhinitis symptoms are needed, given the central role of the self-assessment of symptoms in guideline-based care. Accurate perception of the severity of rhinitis symptoms may enhance rhinitis control, lessen the burden of asthma, and prevent unnecessary emergency use among this high-risk group of children.

Associations between urban air pollution and pediatric asthma control in El Paso, Texas

Exposure to traffic-related pollutants poses a serious health threat to residents of major urban centers around the world. In El Paso, Texas, this problem is exacerbated by the region's arid weather, frequent temperature inversions, heavy border traffic, and an aged, poorly maintained vehicle fleet. The impact of exposure to traffic pollution, particularly on children with asthma, is poorly understood. Tracking the environmental health burden related to traffic pollution in El Paso is difficult, especially within school microenvironments, because of the lack of sensitive environmental health indicator data. The Asthma Control Questionnaire (ACQ) is a survey tool for the measurement of overall asthma control, yet has not previously been considered as an outcome in air pollution health effect research. We conducted a repeated measure panel study to examine weekly associations between ACQ scores and traffic- and non-traffic air pollutants among asthmatic schoolchildren in El Paso. In the main one- and two-pollutant epidemiologic models, we found non-significant, albeit suggestive, positive associations between ACQ scores and respirable particulate matter (PM10), coarse particulate matter (PM10-2.5), fine particulate matter (PM2.5), black carbon (BC), nitrogen dioxide (NO2), benzene, toluene, and ozone (O3). Notably, associations were stronger and significant for some subgroups, in particular among subjects taking daily inhaled corticosteroids. This pattern may indicate heightened immune system response in more severe asthmatics, those with worse asthma "control" and higher ACQ scores at baseline. If the ACQ is appropriately used in the context of air pollution studies, it could reflect clinically measurable and biologically relevant changes in lung function and asthma symptoms that result from poor air quality and may increase our understanding of how air pollution influences asthma exacerbation.

Factors associated with completion of a behavioral intervention for caregivers of urban children with asthma

BACKGROUND

Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma.

OBJECTIVE

The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters.

METHODS

Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child's primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables.

RESULTS

Children were African-American (95%), Medicaid insured (91%), and young (aged 3-5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3-5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention.

CONCLUSIONS

The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.

Cost benefits of a peer-led asthma self-management program for adolescents

OBJECTIVE

Frequent use of health-care services associated with pediatric asthma places substantial economic burden on families and society. The purpose of this study is to examine the cost-saving effects of a peer-led program through reduction in health-care utilization in comparison to an adult-led program.

METHODS

Randomly assigned adolescents (13-17 years) participated in either peer-led (n = 59) or adult-led (n = 53) asthma self-management program. Health-care utilization data were collected at baseline and at 3-, 6-, and 9-months post-intervention. Negative binomial regression models were conducted to examine the effects of the peer-led program on health-care utilization. Net cost savings were estimated based on the differences in program costs and health-care utilization costs between groups.

RESULTS

Significant group differences were found in acute office visits and school clinic visits after controlling for race and socioeconomic status. The incidence rate of acute office visits was 80-82% less for the peer-led group during follow-ups. The peer-led group was four to five times more likely to use school clinics due to asthma than the adult-led group during follow-ups. The non-research cost of peer-led program per participant was lower than the adult-led program, $64 versus $99, respectively. The net cost saving from the reduction in acute office visits and the lower program costs of the peer-led program was estimated $51.8 per person for a 3-month period.

CONCLUSIONS

An asthma self-management program using peer leaders can potentially yield health-care cost savings through the reduction in acute office visits in comparison to a traditional program led by health-care professionals.

Shared decision-making and health care expenditures among children with special health care needs

BACKGROUND AND OBJECTIVES

To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN).

METHODS

We identified CSHCN <18 years in the 2002-2006 Medical Expenditure Panel Survey by using the CSHCN Screener. Outcomes included health care expenditures (total, out-of-pocket, office-based, inpatient, emergency department [ED], and prescription) and utilization (hospitalization, ED and office visit, and prescription rates). The main exposure was the pattern of SDM over the 2 study years (increasing, decreasing, or unchanged high or low). We assessed the impact of these patterns on the change in expenditures and utilization over the 2 study years.

RESULTS

Among 2858 subjects representing 12 million CSHCN, 15.9% had increasing, 15.2% decreasing, 51.9% unchanged high, and 17.0% unchanged low SDM. At baseline, mean per child total expenditures were $2131. Over the 2 study years, increasing SDM was associated with a decrease of $339 (95% confidence interval: $21, $660) in total health care costs. Rates of hospitalization and ED visits declined by 4.0 (0.1, 7.9) and 11.3 (4.3, 18.3) per 100 CSHCN, and office visits by 1.2 (0.3, 2.0) per child with increasing SDM. Relative to decreasing SDM, increasing SDM was associated with significantly lower total and out-of-pocket costs, and fewer office visits.

CONCLUSIONS

We found that increasing SDM was associated with decreased utilization and expenditures for CSHCN. Prospective study is warranted to confirm if fostering SDM reduces the costs of caring for CSHCN for the health system and families.

Medical home and out-of-pocket medical costs for children with special health care needs

OBJECTIVE

We examined key factors that affect out-of-pocket medical expenditures per $1000 of household income for children with special health care needs (CSHCN) with a broad range of conditions, controlling for insurance type and concentrating on the potentially moderating role of the medical home.

METHODS

A Heckman selection model was used to estimate whether the medical home influenced out-of-pocket medical costs per $1000 of household income for children covered by either private or public health insurance. Data from the 2005-2006 National Survey of CSHCN (N = 31,808) were used.

RESULTS

For families that incurred out-of-pocket medical costs for their CSHCN, these costs represented 2.2% to 3.9% of income. Both insurance type and the medical home had significant effects on out-of-pocket costs. Lower out-of-pocket medical costs per $1000 of income were incurred by children with public insurance and those receiving care coordination services.

CONCLUSIONS

Families with CSHCN incur lower out-of-pocket medical costs when their children receive health care in a setting in which the care-coordination component of the medical home is in place.

Patient-reported care coordination: associations with primary care continuity and specialty care use

PURPOSE

Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use.

METHODS

We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use.

RESULTS

Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77).

CONCLUSIONS

High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.

[Cost of childhood asthma in Spain: a cost evaluation model based on the prevalence]

INTRODUCTION

Asthma is the most common chronic disease in childhood, reduces the quality of life of children and their families, and produces high social and health care costs. In Spain, the cost of managing paediatric asthma is unknown.

OBJECTIVE

To estimate the cost of managing paediatric asthma in Spain and to examine its variability depending on asthma severity.

PATIENTS AND METHODS

The cost of asthma in children under 16 years in 2008 was estimated by building a costs assessment model including the factors that influence the cost of asthma in children: prevalence, distribution of disease severity, age, frequency of resources use depending on severity, and the cost of each resource. A sensitivity analysis was conducted to evaluate the underlying uncertainty depending on the variability of the estimators of resource use, the unit cost of each resource, and the prevalence.

RESULTS

According to the model, the total cost of paediatric asthma in Spain is around 532 million euros, with a range of 392 to 693 million euros. Direct costs (health care costs) represent 60% of the total costs, and indirect costs (carer time), 40%. The mean annual cost per child with asthma is 1,149 euros, ranging from 403 euros for the mildest category of the disease to 5,380 euros for the most severe.

CONCLUSIONS

The cost of paediatric asthma in Spain is very high and depends on disease severity. Although the most important costs are for the health care system, indirect costs are not negligible.

The Breathmobile program: a good investment for underserved children with asthma

BACKGROUND

The Breathmobile, a specialty-based mobile asthma clinic, provides free care to underserved children. The cost of symptom-free day (SFD) improvement in this population has not been previously reported.

OBJECTIVE

To examine the clinical impact and cost-effectiveness of the Baltimore Breathmobile.

METHODS

Existing computerized data were analyzed for Breathmobile patient visits between 2002 and 2007. All SFDs were calculated, and direct medical cost savings attributable to decreased emergency department visits and hospitalizations (after program utilization vs the previous year) were compared with annual operating costs. Incremental cost-effectiveness ratios were determined by calculating the incremental costs of Breathmobile care per additional SFD gained per child per year.

RESULTS

The analysis included 255 patients enrolled in the program for at least 1 year. Most participants were black (93.3%), and 54.9% were male. At baseline, patients reported a mean (SD) of 199 (118) SFDs in the year before enrollment. After 1 year in the program, patients had a mean (SD) improvement of 44 (9) SFDs. The program resulted in overall cost savings of $79.43 per SFD gained, with greater cost savings for children aged 5 to 11 years (-$116.84 per SFD gained) and those with intermittent asthma (-$126.71 per SFD gained).

CONCLUSIONS

The Baltimore Breathmobile program has demonstrated significant improvement in SFDs, with direct medical cost savings of the program outweighing the operational costs. These data support the need to continue to sustain and expand Breathmobile programs for children at high risk for asthma exacerbations and to conduct a randomized clinical trial to estimate the cost-effectiveness of the Breathmobile.

Economic burden of asthma: implications for outcomes and cost-effectiveness analyses

Asthma is a disease of chronic airway inflammation. It is of importance to clinicians and health systems because the hospitalization and death rate due to asthma have increased since 1980. Cost of illness studies have estimated that the total cost of asthma (direct and indirect costs) exceed USD 10 billion annually, in the USA. Since 1985, the proportion of asthma costs in hospitals have decreased and the proportion of costs due to asthma medications have increased. However, approximately half of direct medical costs of asthma are due to hospitalizations. The mean direct cost of asthma per year per patient has been estimated to be approximately USD 1,100. As the implementation of national and international guidelines continues, future costs for asthma will likely come from the treatment and management of the disease. Adequate assessments of treatment and cost-effectiveness analysis are important. Recommendations promoting the use of cost-effective anti-inflammatory medications are crucial to efficiently managing asthma.

Direct non-medical and indirect costs for families with children with congenital cardiac defects in Germany: a survey from a university centre

INTRODUCTION

Parents of children with congenital cardiac disease suffer from psychological stress and financial burdens. These costs have not yet been quantified.

MATERIALS AND METHODS

In cooperation with paediatricians, social workers, and parents, a questionnaire was devised to calculate direct non-medical and indirect costs. Direct non-medical costs include all costs not directly related to medical services such as transportation. Indirect costs include lost productivity measured in lost income from wages. Parents were retrospectively queried on costs and refunds incurred during the child's first and sixth year of life. The questionnaire was sent out to 198 families with children born between 1980 and 2000. Costs were adjusted for inflation to the year 2006. Children were stratified into five groups according to the severity of their current health status.

RESULTS

Fifty-four families responded and could be included into the analysis (27.7%). Depending on severity, total direct non-medical and indirect costs in the first year of life ranged between an average of euro1654 in children with no or mild (remaining) cardiac defects and an average euro2881 in children with clinically significant (residual/remaining) findings. Mean expenses in the sixth year of life were as low as euro562 (no or mild (remaining) cardiac defects) and as high as euro5213 (potentially life-threatening findings). At both points in time, the highest costs were lost income and transportation; and day care/ babysitting for siblings was third.

DISCUSSION

Families of children with congenital cardiac disease and major sequelae face direct non-medical and indirect costs adding up to euro3000 per year on average. We should consider compensating families from low socioeconomic backgrounds to minimise under-use of non-medical services of assistance for their children.

Economic burden of asthma: a systematic review

BACKGROUND

Asthma is associated with enormous healthcare expenditures that include both direct and indirect costs. It is also associated with the loss of future potential earnings related to both morbidity and mortality. The objective of the study is to determine the burden of disease costs associated with asthma.

METHODS

We performed a systematic search of MEDLINE, EMBASE, CINAHL, CDSR, OHE-HEED, and Web of Science Databases between 1966 and 2008.

RESULTS

Sixty-eight studies met the inclusion criteria. Hospitalization and medications were found to be the most important cost driver of direct costs. Work and school loss accounted for the greatest percentage of indirect costs. The cost of asthma was correlated with comorbidities, age, and disease severity.

CONCLUSION

Despite the availability of effective preventive therapy, costs associated with asthma are increasing. Strategies including education of patients and physicians, and regular follow-up are required to reduce the economic burden of asthma.

Healthcare utilization and expenditures for low income children with sickle cell disease

BACKGROUND

While multiple studies have examined the healthcare burden of sickle cell disease (SCD) in adults, few have specifically focused on healthcare utilization and expenditures in children. The objective of this study was to characterize the healthcare utilization and costs associated with the care of low-income children with SCD in comparison to other children of similar socioeconomic status.

PROCEDURE

For the study period, 2004-2007, we conducted a retrospective, cross-sectional descriptive analysis of administrative claims data from a managed care plan exclusively serving low-income children with Medicaid and the State Children's Health Insurance Plan (SCHIP). Patient demographics, continuity of insurance coverage, healthcare utilization, and expenditures were collected for all children enrolled with SCD and the general population within the health plan for comparison.

RESULTS

On average, 27% of members with SCD required inpatient hospitalization and 39% utilized emergency care in a given calendar year. Both values were significantly higher than those of the general health plan population (P < 0.0001). Across the study period, 63% of members with SCD averaged one well child check per year and 10% had a minimum of one outpatient visit per year to a hematologist for comprehensive specialty care.

CONCLUSIONS

Low-income children with SCD demonstrate significantly higher healthcare utilization for inpatient care, emergency center care, and home health care compared to children with similar socio-demographic characteristics. A substantial proportion of children with SCD may fail to meet minimum guidelines for outpatient primary and hematology comprehensive care.

Financial burden in families of children with special health care needs: variability among states

OBJECTIVE

The main objective of this study was to examine variability among states for 3 indicators of the family financial burden related to caring for children with special health care needs.

METHODS

Data were from a 2001 national survey of households with children (<18 years of age) with special health care needs, with a representative sample from each state. The outcomes examined included whether a family had any out-of-pocket expenditures during the previous 12 months related to the child's special health care needs, the amount of expenditure (absolute burden), and the amount of expenditure per $1000 of family income (relative burden). We used multilevel regression to examine state-level variability in financial burden, controlling for individual-level factors. We also examined the association between state median family income and state mean financial burden.

RESULTS

Overall, 82.5% of families reported expenditures of more than $0. Among these families, the mean unadjusted absolute burden was $752 and the relative burden was $19.6 per $1000. Adjusted state means ranged from $562 to $972 for absolute burden and from $14.5 to $32.3 per $1000 for relative burden. Families living in states with higher median family incomes had lower financial burdens across all 3 measures.

CONCLUSIONS

Families that are similar with respect to household demographic characteristics and the nature of their children's special health care needs have different out-of-pocket health expenditures depending on the state in which they live. Documenting and understanding this variability moves the field closer to the goal of establishing evidence-based, state policy recommendations aimed at reducing the financial burden of these vulnerable families.

The contributing role of health-care communication to health disparities for minority patients with asthma

Asthma is a common, chronic illness with substantial morbidity, especially for racial and ethnic minorities in the United States. The care of the patient with asthma is complex and depends ideally on excellent communication between patients and health-care providers. Communication is essential for the patient to communicate the severity of his or her illness, as well as for the health-care provider to instruct patients on pharmacologic and nonpharmacologic care. This article describes evidence for poor provider/patient communication as a contributor to health-care disparities for minority patients with asthma. Communication problems stem from issues with patients, health-care providers, and health-care systems. It is likely that asthma disparities can be improved, in part, by improving patient/provider communication. While much is known presently about the problem of patient/provider communication in asthma, there is a need to improve and extend the evidence base on the role of effective communication of asthma care and the links to outcomes for minorities. Additional studies are needed that document the extent to which problems with doctor/patient communication lead to inadequate care and poor outcomes for minorities with asthma, as well as mechanisms by which these disparities occur.

The effect of comorbid anxiety and depressive disorders on health care utilization and costs among adolescents with asthma

OBJECTIVE

To assess whether youth with asthma and comorbid anxiety and depressive disorders have higher health care utilization and costs than youth with asthma alone.

METHODS

A telephone survey was conducted among 767 adolescents (aged 11 to 17 years) with asthma. Diagnostic and Statistical Manual-4th Version (DSM-IV) anxiety and depressive disorders were assessed via the Diagnostic Interview Schedule for Children. Health care utilization and costs in the 12 months pre- and 6 months post-interview were obtained from computerized health plan records. Multivariate analyses were used to determine the impact of comorbid depression and anxiety on medical utilization and costs.

RESULTS

Unadjusted analyses showed that compared to youth with asthma alone, youth with comorbid anxiety/depressive disorders had more primary care visits, emergency department visits, outpatient mental health specialty visits, other outpatient visits and pharmacy fills. After controlling for asthma severity and covariates, total health care costs were approximately 51% higher for youth with depression with or without an anxiety disorder but not for youth with an anxiety disorder alone. Most of the increase in health care costs was attributable to nonasthma and non-mental health-related increases in primary care and laboratory/radiology expenditures.

CONCLUSIONS

Youth with asthma and comorbid depressive disorders have significantly higher health care utilization and costs. Most of these costs are due to increases in non-mental health and nonasthma expenses. Further study is warranted to evaluate whether improved mental health treatment and resulting increases in mental health costs would be balanced by savings in medical costs.

Intimate partner violence and health care costs and utilization for children living in the home

OBJECTIVE

The goal was to determine whether differences in health care costs and utilization exist for children whose mothers experienced intimate partner violence versus those who did not.

METHODS

A longitudinal cohort study was performed in an integrated health care delivery organization with 760 children of mothers with no history of intimate partner violence and 631 children of mothers with a history of intimate partner violence since age 18. Health care utilization and costs for children before, during, and after intimate partner violence exposure were compared with utilization and costs for children with nonabused mothers.

RESULTS

Health care utilization and health care costs were higher in most categories of care for children of mothers with a history of intimate partner violence, with significantly higher values for mental health services, primary care visits, primary care costs, and laboratory costs. Children of mothers with a history of intimate partner violence that ended before the child was born had significantly greater utilization of mental health, primary care, specialty care, and pharmacy services than did children of mothers who reported no intimate partner violence. Children exposed directly to intimate partner violence (after birth) had greater emergency department and primary care use during the intimate partner violence and were 3 times as likely to use mental health services after the intimate partner violence ended.

CONCLUSIONS

Children whose mothers experienced intimate partner violence have higher health care utilization and costs, even if their mothers' abuse stopped before they were born. Screening of women for intimate partner violence should be a routine part of their health care, and interventions for both the women and their children are likely necessary to minimize the effects of intimate partner violence in the family.

Persistence of high health care expenditures among children in Medicaid

Cross-sectional studies show that a small percentage of children consume a large portion of the health care dollar. However, little is known about the persistence of high health care expenditures among children enrolled in Medicaid health maintenance organizations (HMOs) or in primary care case management (PCCM) programs. This study found substantial expenditure persistence during a 3-year period. Among Temporary Aid to Needy Families (TANF) children in HMOs in the top 10 percent of the expenditure distribution in 2003, 34 percent remained in the top 10 percent in 2004, and 23 percent remained in the top 10 percent in 2005. Similar patterns were observed for TANF children in the PCCM. Expenditure persistence varied based on the enrollees' enabling and need characteristics, providing opportunities to identify children with high health care expenditures who may benefit from care coordination.

Risk of recurrent emergency department visits or hospitalizations in children with asthma receiving nebulized budesonide inhalation suspension compared with other asthma medications

OBJECTIVE

To examine whether nebulized budesonide inhalation suspension treatment reduces asthma-related emergency department visit/hospitalization recurrence risk in children compared with other asthma medications, particularly non-nebulized inhaled corticosteroids.

RESEARCH DESIGN AND METHODS

Longitudinal, retrospective claims analysis of data from a managed care organization database in the United States (July 1, 2000-June 30, 2002). Participants were children aged < or = 8 years with an asthma diagnosis and asthma-related emergency department visit or hospitalization (index event). Asthma medication use, evaluated by asthma-related prescriptions < or = 30 days after the index event, determined treatment groups.

MAIN OUTCOME MEASURE

Emergency department visit/hospitalization recurrence risk from post-index day 31-180 across treatment groups.

RESULTS

Of 10,176 patients with an index event, 13% experienced a post-index recurrence. For patients receiving asthma prescriptions < or = 30 days after the index event, those receiving budesonide inhalation suspension showed a significant reduction in emergency department visit/hospitalization recurrence risk compared with those not prescribed this treatment (adjusted hazard ratio, 0.71; 95% confidence interval, 0.57-0.89). For patients receiving asthma controller medication in the post-index period, those receiving budesonide inhalation suspension had a significantly lower recurrence risk than patients receiving prescriptions for other controller medications (hazard ratio, 0.71; 95% confidence interval, 0.52-0.97). Recurrence risk was significantly reduced (53%) in patients receiving budesonide inhalation suspension prescriptions compared with non-nebulized inhaled corticosteroid prescriptions (hazard ratio, 0.47; 95% confidence interval, 0.28-0.78).

CONCLUSION

For children aged < or = 8 years, budesonide inhalation suspension treatment after an asthma-related emergency department visit/hospitalization was associated with a significantly reduced risk of recurrence compared with other asthma medications and with non-nebulized inhaled corticosteroids. Because this was an observational study, results should be interpreted cautiously. However, this study allowed evaluation of treatment in real-world practice settings not often included in clinical trials.

Healthcare utilization and costs for women with a history of intimate partner violence

OBJECTIVE

To determine the healthcare utilization and medical care costs of women with a history of intimate partner violence (IPV) compared to women without a history of IPV.

DESIGN

Longitudinal cohort study.

SETTING

Mixed-model health maintenance organization.

PARTICIPANTS

Over 3000 (3333) women aged 18 to 64 years with > or = 3 year's cumulative enrollment prior to the survey, at least 1 year of which was after the 18th birthday.

MAIN EXPOSURE

IPV since age 18 as determined from responses to telephone interview using questions from the Behavioral Risk Factor Surveillance System and also the Women's Experience with Battering Scale.

OUTCOME MEASURES

Healthcare utilization and costs (from automated data) during the time that IPV occurred and following its cessation, compared to healthcare utilization for women who did not report IPV since age 18.

RESULTS

A total of 1546 women reported IPV in their lifetime; at the time of interview, IPV had ceased in 87% of women, on average 16.0 years prior to interview. Healthcare utilization was higher for all categories of service during IPV compared to women without IPV, and decreased over time after cessation of IPV. However, healthcare utilization was still 20% higher 5 years after women's abuse ceased compared to women without IPV. Adjusted annual total healthcare costs were 19% higher in women with a history of IPV (amounting to $439 annually) compared to women without IPV. Based on prevalence for IPV of 44%, the excess costs due to IPV are approximately $19.3 million per year for every 100,000 women enrollees aged 18-64.

CONCLUSIONS

Women with a history of IPV had significantly higher healthcare utilization and costs, continuing long after IPV ended. Given its high prevalence, IPV has a major impact on medical care resource utilization and efforts to prevent its occurrence and consequences are clearly indicated.

The Impact of Managed Care Enrollment on Emergency Department Use Among Children With Special Health Care Needs

BACKGROUND

Many states recently have experimented with managed care as a way both to control costs and to enhance continuity of care in their publicly financed programs. A few states have applied managed care models to the care of chronically ill children. One marker for the effects of managed care is changes in use of the emergency department (ED).

OBJECTIVE

We sought to determine whether a managed care program can reduce ED use for children with chronic health problems.

SUBJECTS

We studied chronically ill children who were dually enrolled in Michigan's Title V program for children with special health care needs and Medicaid and who were enrolled in a managed care option at some time during the study period. The managed care model emphasized care coordination and did not include strong financial incentives for utilization and cost control. Sample consisted of 8580 person-months.

METHOD

We used a fixed-effect negative binomial Poisson regression model to compare ED use before and after joining a managed care plan to test whether managed care use was associated with reduced likelihood of ED use.

RESULTS

Managed care enrollment was associated with a 23% reduction in the incidence of ED use among children dually enrolled in Medicaid and Title V.

CONCLUSIONS

A managed care model is associated with statistically significant and substantive reductions in observed use of ED care within an important population of children facing chronic illness.

Changes in health care costs before and after smoking cessation

Previous research on health care costs among former smokers suggests that quitters incur greater health care costs for up to 4 years after cessation compared with continuing smokers. However, little is known about the relationship between health care costs and utilization in the periods before as well as after cessation. The present study used a retrospective cohort design with automated health plan and primary data to examine the health care costs and clinical experiences before and after smoking cessation among former smokers compared with a sample of continuing smokers. Subjects were a random sample of adults (aged 25 and older) whose smoking status was identified by a physician during a primary care visit to the Group Health Cooperative (GHC), a nonprofit, integrated health care delivery system in western Washington state. Total direct health care costs among former smokers began to rise in the quarter prior to cessation and were significantly greater (p < .001) than those of continuing smokers in the quarter immediately following cessation. This difference dissipated within one quarter following cessation. We replicated the postquit cost spike among former smokers found by other research and showed that this spike dissipated within the first year postquit. Smoking cessation did not result in sustained cost increases among former smokers.

Is there a best outcome measurement for patients with asthma?

OBJECTIVES

To summarize the outcomes used to evaluate inhaled corticosteroid intervention in terms of the Economic, Clinical, and Humanistic Outcomes (ECHO) model and to discuss the value of this more comprehensive approach in assessing therapeutic efficacy in asthma.

DATA SOURCES

Relevant articles were identified by a search of the PubMed database for English-language articles published from 1991 to 2006 and references identified from bibliographies of relevant articles.

STUDY SELECTION

The author's expert opinion was used to select studies for inclusion in this review.

RESULTS

Studies that assessed therapeutic effectiveness of inhaled corticosteroids in patients with asthma have traditionally focused on clinical indicators of treatment effect, including pulmonary function and symptoms. However, reliance on clinical indicators alone may not represent the full effect of the treatment on patients with asthma. The ECHO model is proposed as a more comprehensive and useful alternative to evaluate therapeutic effectiveness in patients with asthma. The model takes into account more recent concerns of patients and health care practitioners, including quality of life and treatment cost. Clinical studies using various ECHO outcomes are presented and the limitations of using individual outcomes are discussed. The Pediatric Asthma Episodes of Care Program, which exemplifies successful application of the ECHO model in the real-world setting, is also discussed.

CONCLUSIONS

The more comprehensive approach to determining therapeutic effectiveness in asthma provided by the ECHO model should enable optimization of asthma treatment, with limited health care resources.

Direct health care costs for children with pervasive developmental disorders: 1996-2002

We compared direct costs of treatment of Pervasive Developmental Disorder (PDD), asthma, and diabetes in children aged 3-17 years. A retrospective, claims-based study was conducted using the California Medicaid (Medi-Cal) database (1996-2002). Seven hundred and thirty-one children with PDD were identified and matched for sex with an equal number of randomly selected children with asthma and diabetes. Mean total health care costs for PDD were two- to threefold higher than for asthma and diabetes post-diagnosis ($4,815 vs. $1,469 vs. $2,404, respectively, P < 0.0001). Children with PDD incur significantly greater health care costs when compared with children with other chronic pediatric diseases.

The economic impact of children dispensed asthma medications without an asthma diagnosis

OBJECTIVE

To compare the resource utilization and healthcare costs of children with a diagnosis of asthma, children dispensed asthma medications but without a diagnosis of asthma, and control children.

STUDY DESIGN

Children 0 to 17 years old were identified from an integrated managed-care database during calendar year 2001. They were compared on the basis of the presence of a medical claim for asthma (Dx cohort); a prescription for an asthma controller or reliever medication (excluding oral corticosteroids) but without an asthma diagnosis (Rx cohort), and control children. Using medical and pharmacy claims, resource utilization and costs were compared across cohorts.

RESULTS

Children in both the Dx and Rx cohorts had significantly greater nonasthma and total all-cause annual healthcare costs compared with control children. The Dx and Rx cohorts had higher rates of nonasthma emergency department visits and hospitalizations. The risk of an oral corticosteroid dispensed was 14-fold and 7-fold greater for the Dx and Rx cohorts, respectively, compared with the control children. These findings were consistent in infant, toddler, school-age, and adolescent groups.

CONCLUSIONS

Children dispensed asthma medications but lacking an asthma diagnosis have considerable morbidity and incur high healthcare resource utilization. This study suggests that better recognition of pediatric asthma is warranted.

Predictors of hospital charges for children admitted with asthma

OBJECTIVES

To examine patient and hospital characteristics associated with varying hospital charges for children admitted with asthma.

METHODS

We conducted a retrospective cohort study of children (1-18 years old) hospitalized with asthma using data from the 2000 Kids' Inpatient Database (KID; n = 54,029). Predictors of interest included hospital type (teaching and children's hospitals) and patient characteristics (insurance type and race).

RESULTS

After adjusting for patient and hospital characteristics, hospital charges were similar at teaching and nonteaching hospitals. Charges at children's hospitals were higher by 440 US dollars or 10% (95% CI, 352-528) compared with nonchildren's hospitals. Children with Medicaid had higher charges by 132 US dollars or 3% (95% CI, 57-264) compared to those with private insurance. Compared to White children, Black children had higher charges by 396 US dollars or 10% (95% CI, 352-484), Hispanic children by 924 US dollars or 21% (95% CI, 880-1,012), and Asian children by 572 US dollars or 13% (572 US dollars; 95% CI, 352-792).

CONCLUSIONS

Important differences exist in the charges incurred by children with asthma based on patient and hospital characteristics. Efforts to understand the reasons behind the differences may help eliminate unnecessary variation in costs for asthma care.

Reliability of Group Health Cooperative automated pharmacy data by drug benefit status

PURPOSE

Evaluate the reliability of health plan pharmacy records in determining medication use among seniors with and without a drug benefit.

METHODS

Subjects included 3610 seniors, enrolled in Group Health Cooperative's Medicare (GHC) + Choice program during 1998-1999, receiving care in an integrated group practice (IGP), and diagnosed with one or more of four chronic conditions (hypertension, diabetes, congestive heart failure, and coronary artery disease). We compared pharmacy records to self-reported medication use for antidepressant, antihypertensive, acid suppressant, cardiac, diabetic, hormone, and lipid lowering drugs.

RESULTS

Agreement between pharmacy records and self-report was substantial to almost perfect (prevalence-adjusted and bias-adjusted kappa (PABAK) range: 0.69 for antihypertensives to 0.95 for cardiac agents) among seniors with a drug benefit. Agreement was slightly less for seniors without a drug benefit (PABAK range: 0.51 for antihypertensives to 0.92 for cardiac agents) and differences varied by drug class. Among seniors without a benefit, the prevalence of medication use was lower when based on pharmacy records than when based on self-report for all medication classes of interest.

CONCLUSIONS

While GHC may not be representative of all health plans, our study indicates that health plan pharmacy records are a reliable source of data for seniors receiving care within an IGP. However, the reliability of pharmacy records appears better among seniors with a drug benefit. Researchers should consider factors such as drug benefit status when conducting studies using pharmacy data. More studies are needed in different populations and delivery systems, as well as over varied types of drug benefits.

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.

Variation in pediatric asthma quality improvement programs by managed care plans

Although asthma quality improvement (QI) programs are common, little is known about the scope and content of QI initiatives in managed care arrangements. The authors conducted a cross-sectional survey of all managed care plans in Michigan serving the pediatric Medicaid population. Using semi-structured interviews, they assessed the comprehensiveness of the asthma QI program regarding provider, allied health professional, pharmacy, and member services. Although all QI initiatives included some type of physician-directed component and patient-directed components, only half included allied health professionals and one quarter included pharmacy-directed components. Interactive physician continuing medical education was associated with plans whose members were concentrated in only 1 or 2 counties. The authors noted wide variation in content, format, inclusion of incentives, inclusion of other health professionals, and outcome goals. The variation in QI approaches by each of the managed care organizations suggests that there is a dearth of information on appropriate and cost-effective methods to improve pediatric asthma quality at the plan level.

Regional variation in ICU care for pediatric patients with asthma

OBJECTIVE

To determine adherence to guidelines for severe asthma care and evaluate regional variability in practice among pediatric intensive care units (PICU).

STUDY DESIGN

A retrospective cohort study of children treated for asthma in a PICU during 2000 to 2003. We utilized the Pediatric Health Information System (PHIS) database to identify patients and determine use of asthma therapies when patients did not improve with standard therapy (inhaled beta-agonists and systemic corticosteroids).

RESULTS

Of 7125 children studied, 59% received inhaled anticholinergic medications. Use of other therapies included systemic beta-agonists (n = 1841 [26%]), magnesium sulfate (n = 1521 [21%]), methylxanthines (n = 426 [6%]), inhaled helium-oxygen gas mixture (heliox) (n = 740 [10%]), and endotracheal intubation with ventilation (n=1024 [14%]). Use of therapies varied by census region. Over half the patients (n = 524) who received ventilation did so for < or = 1 day. Adjusted for severity of illness, use of mechanical ventilation varied significantly by census division; however, much of the variation was among children ventilated for < or = 1 day.

CONCLUSION

Adherence to national guidelines for use of inhaled anticholinergics among critically ill children is low, and marked variation in use of invasive ventilation exists. More explicit guidelines regarding indications for invasive ventilation may improve asthma care.

An international observational prospective study to determine the cost of asthma exacerbations (COAX)

Asthma is a common chronic condition that places substantial burden on patients and healthcare services. Despite the standards of asthma control that international guidelines recommend should be achieved, many patients continue to suffer sub-optimal control of symptoms and experience exacerbations (acute asthma attacks). In addition to being associated with reduced quality of life, asthma exacerbations are a key cost driver in asthma management. Routine clinical practice for the management of asthma exacerbations varies in different healthcare systems, so healthcare providers require local costs to be able to assess the value of therapies that reduce the frequency and severity of exacerbations. This prospective study, conducted in a total of 15 countries, assessed the local cost of asthma exacerbations managed in either primary or secondary care. Healthcare resources used were costed using actual values appropriate to each country in local currency and in Euros. Results are presented for exacerbations managed in primary care in Brazil, Bulgaria, Croatia, Czech Republic, Hungary, Poland, Russia, Slovakia, Slovenia, Spain and Ukraine, and in secondary care in Croatia, Denmark, Ireland, Latvia, Norway, Poland, Russia, Slovakia, Slovenia and Spain. Multiple regression analysis of the 2052 exacerbations included in the economic analysis showed that the cost of exacerbations was significantly affected by country (P<0.0001). Mean costs were significantly higher in secondary care (euro 1349) than primary care (euro 445, P=0.0003). Age was a significant variable (P=0.0002), though the effect showed an interaction with care type (P<0.0001). As severity of exacerbation increased, so did secondary care costs, though primary care costs remained essentially constant. In conclusion, the study showed that asthma exacerbations are costly to manage, suggesting that therapies able to increase asthma control and reduce the frequency or severity of exacerbations may bring economic benefits, as well as improved quality of life.

The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers

OBJECTIVES

We assessed the effectiveness of a community health worker intervention focused on reducing exposure to indoor asthma triggers.

METHODS

We conducted a randomized controlled trial with 1-year follow-up among 274 low-income households containing a child aged 4-12 years who had asthma. Community health workers provided in-home environmental assessments, education, support for behavior change, and resources. Participants were assigned to either a high-intensity group receiving 7 visits and a full set of resources or a low-intensity group receiving a single visit and limited resources.

RESULTS

The high-intensity group improved significantly more than the low-intensity group in its pediatric asthma caregiver quality-of-life score (P=.005) and asthma-related urgent health services use (P=.026). Asthma symptom days declined more in the high-intensity group, although the across-group difference did not reach statistical significance (P=.138). Participant actions to reduce triggers generally increased in the high-intensity group. The projected 4-year net savings per participant among the high-intensity group relative to the low-intensity group were 189-721 dollars.

CONCLUSIONS

Community health workers reduced asthma symptom days and urgent health services use while improving caregiver quality-of-life score. Improvement was greater with a higher-intensity intervention.

Measuring the effectiveness of a collaborative for quality improvement in pediatric asthma care: does implementing the chronic care model improve processes and outcomes of care?

OBJECTIVE

To examine whether a collaborative to improve pediatric asthma care positively influenced processes and outcomes of that care.

METHODS

Medical record abstractions and patient/parent interviews were used to make pre- and postintervention comparisons of patients at 9 sites that participated in the evaluation of a Breakthrough Series (BTS) collaborative for asthma care with patients at 4 matched control sites.

SETTING

Thirteen primary care clinics.

PATIENTS

Three hundred eighty-five asthmatic children who received care at an intervention clinic and 126 who received care at a control clinic (response rate = 76%).

INTERVENTION

Three 2-day educational sessions for quality improvement teams from participating sites followed by 3 "action" periods over the course of a year.

RESULTS

The overall process of asthma care improved significantly in the intervention group but remained unchanged in the control group (change in process score +13% vs 0%; P < .0001). Patients in the intervention group were more likely than patients in the control group to monitor their peak flows (70% vs 43%; P < .0001) and to have a written action plan (41% vs 22%; P = .001). Patients in the intervention group had better general health-related quality of life (scale score 80 vs 77; P = .05) and asthma-specific quality of life related to treatment problems (scale score 89 vs 85; P < .05).

CONCLUSIONS

The intervention improved some important aspects of processes of care that have previously been linked to better outcomes. Patients who received care at intervention clinics also reported higher general and asthma-specific quality of life.

Association between allergic rhinitis and hospital resource use among asthmatic children in Norway

BACKGROUND

Preliminary evidence suggests that inadequately controlled allergic rhinitis in asthmatic patients can contribute towards increased asthma exacerbations and poorer symptom control, which may increase medical resource use. The objective of this study was therefore to assess the effect of concomitant allergic rhinitis on asthma-related hospital resource utilization among children below 15 years of age with asthma in Norway.

METHODS

A population-based retrospective cohort study of children (aged 0-14 years) with asthma was conducted using data from a patient-specific public national database of hospital admissions during a 2-year period, 1998-1999. Multivariate linear regression, adjusting for risk factors including age, gender, year of admission, urban/rural residence and severity of asthma episode, estimated the association between allergic rhinitis and total hospital days. A multivariate Cox proportional-hazards model estimated relative hazard of readmission according to concomitant allergic rhinitis status.

RESULTS

Among 2961 asthmatic children under 15 years of age with at least one asthma-related hospital admission over a 2-year period, 795 (26.8%) had a recorded history of allergic rhinitis. Asthmatic children with allergic rhinitis had a 1.72-times greater hazard of asthma-related readmissions than asthmatic children without allergic rhinitis. Multivariate analysis revealed that history of concomitant allergic rhinitis was a significant predictor of increased number of hospital days per year (least-squares mean difference 0.23 days, P < 0.05).

CONCLUSIONS

Concomitant allergic rhinitis in asthmatic children was associated with increased likelihood of asthma-related hospital readmissions and greater total hospital days.

The development and establishment of a care map in children with asthma in Taiwan

BACKGROUND

It is often difficult to predict the timing and frequency of asthma attacks. In addition to interrupting the daily life of both the affected child and his/her family, asthma can also pose sudden danger to a child. Based on clinical observations, many asthma-affected children and their parents must constantly adjust themselves to the uncertainty of the disease, which leads to increased stress on the family. The use of care maps has demonstrated increased efficiency and effectiveness in the care of asthma patients from a variety of settings.

OBJECTIVE

We designed this study to construct and evaluate a care map for asthmatic children in Taiwan. Specific attention was placed on comparing the study and control subjects by parental knowledge of asthma, medication used for asthma, hospital readmission, and health care resource usage.

SUBJECTS AND METHODS

The care map was constructed by in-depth interviews with eight sets of parents of children with asthma. Forty-four parents of 42 asthma children were randomized into two groups in the Allergic Clinic of the Chang Gung Children's Hospital. The experimental group of 22 parents received individual instruction and training sessions in addition to the regular care provided to the control group of 22 parents.

RESULTS

Forty-two children with asthma were surveyed in this study. To examine the reliability and validity of a care map for children with asthma, a quantitative survey was conducted with 42 outpatient parents with asthmatic children. There was less emergency room attending rate in experimental group (6/month; p<0.05) The understanding of the disease was much improved in parents of experimental group (13.85+/-1.04 vs. 10.91+/-2.14; p<0.01). Furthermore, parents acquired a more positive attitude to asthma, and almost all of the control group had irregular follow-ups by a physician and had irregular use of medication.

CONCLUSION

This study emphasizes that a care map in children with asthma (CACM) can be used to educate parents in how to provide the best treatment plan for their children. This study also shows how a CACM can help parents train their children in the best behaviors during asthma attacks. Empathetic assessment and elimination of cultural barriers, a well-designed educational program, and a mutually developed treatment plan could significantly improve the quality of life for families and specific asthma outcomes.

Asthma-related health care resource use among asthmatic children with and without concomitant allergic rhinitis

OBJECTIVE

To determine the incremental effect of allergic rhinitis on health care resource use in children with asthma.

DESIGN

Population-based historical cohort study.

SETTING

Data in a general practice database in the United Kingdom during 1998 to 2001.

PATIENTS

Children 6 to 15 years old with asthma and with >or=1 asthma-related visits to a general practitioner (GP) during a 12-month follow-up period.

MAIN OUTCOME MEASURES

Asthma-related hospitalizations, GP visits, and prescription drug costs during the 12-month follow-up period for patients with and without comorbid allergic rhinitis.

RESULTS

Of 9522 children with asthma, 1879 (19.7%) had allergic rhinitis recorded in the GP medical records. Compared with children with asthma alone, children with comorbid allergic rhinitis experienced more GP visits (4.4 vs 3.4) and more of them were hospitalized for asthma (1.4% vs 0.5%) during the 12-month follow-up period. In multivariable regression analyses, comorbid allergic rhinitis was an independent predictor of hospitalization for asthma (odds ratio: 2.34; 95% confidence interval [CI]: 1.41-3.91) and was associated with increases in the number of asthma-related GP visits (mean increase: 0.53; 95% CI: 0.52-0.54) and asthma drug costs (mean increase pound: 6.7; 95% CI: 6.5-7.0). The association between allergic rhinitis and higher costs of prescriptions for asthma drugs was independent of asthma severity, measured indirectly by the intensity of use of asthma drugs.

CONCLUSIONS

Children with comorbid allergic rhinitis incurred greater prescription drug costs and experienced more GP visits and hospitalizations for asthma than did children with asthma alone. A unified treatment strategy for asthma and allergic rhinitis, as recommended by the Allergic Rhinitis and Its Impact on Asthma initiative, might reduce the costs of treating these conditions.

Prescription Drug Coverage, Health, and Medication Acquisition Among Seniors With One or More Chronic Conditions

BACKGROUND

The unabated rise in medication costs particularly affects older persons with chronic conditions that require long-term medication use, but how prescription benefits affect medication adherence for such persons has received limited study.

OBJECTIVE

We sought to study the relationship among prescription benefit status, health, and medication acquisition in a sample of elderly HMO enrollees with 1 or more common, chronic conditions.

RESEARCH DESIGN

We implemented a cross-sectional cohort study using primary survey data collected in 2000 and administrative data from the previous 2 years.

SUBJECTS

Subjects were aged 67 years of age and older, continuously enrolled in a Medicare + Choice program for at least 2 years, and diagnosed with 1 or more of hypertension, diabetes, congestive heart failure, and coronary artery disease (n = 3073).

MEASURES

Outcomes were the mean daily number of essential therapeutic drug classes and refill adherence.

RESULTS

In multivariate models, persons without a prescription benefit acquired medications in 0.15 fewer therapeutic classes daily and experienced lower refill adherence (approximately 7 fewer days of necessary medications during the course of 2 years) than those with a prescription benefit. A significant interaction revealed that, among those without a benefit, persons in poor health acquired medications in 0.73 more therapeutic classes daily than persons in excellent health; health status did not significantly influence medication acquisition for those with a benefit.

CONCLUSIONS

Coverage of prescription drugs is important for improving access to essential medications for persons with the studied chronic conditions. A Medicare drug benefit that provides unimpeded access to medications needed to treat such conditions may improve medication acquisition and, ultimately, health.

Asthma management practices at home in young inner-city children

Information on parental asthma management practices for young children is sparse. The objective of this article is to determine if specific caregiver asthma management practices for children were associated with children's asthma morbidity. Caregivers of 100 inner-city children diagnosed with persistent asthma and participating in an ongoing asthma intervention study were enrolled and interviewed to ascertain measures of asthma morbidity, medication use, health care use (acute and primary care), and asthma management practices. Overall, asthma morbidity was high with almost two thirds of caregivers reporting their child having one or more emergency department visits within the last 6 months and 63% receiving specialty care for their asthma. Appropriate medication use was reported predominantly as albuterol and inhaled steroids (78%). However, only 42% of caregivers reported administering asthma medicines when their child starts to cough and less than half (39%) reported having an asthma action plan. There were no significant differences by asthma severity level for any asthma management practice. In conclusion, caregivers lack knowledge regarding cough as an early asthma symptom. Caregivers should be encouraged to review asthma action plans with health care providers at each medical encounter.

Physician asthma education program improves outcomes for children of low-income families

STUDY OBJECTIVES

To determine whether an interactive physician seminar that has been shown to improve patient/parent satisfaction and to decrease emergency department visits for children with asthma was also effective for those children from low-income families.

DESIGN

Seventy-four pediatricians and 637 of their patients were randomized to receive two asthma seminars or no educational programs and were observed for 2 years.

SETTING

Physicians in the New York, NY, and Ann Arbor, MI, areas were enrolled, and, on average, 10 patients with asthma per provider were surveyed and observed for 2 years.

PATIENTS OR PARTICIPANTS

A total of 637 subjects were enrolled, and 369 subjects remained in the study after 2 years. Of these, 279 had complete medical and survey information.

INTERVENTIONS

Physicians were randomized, and then a random sample of their patients was enrolled and surveyed regarding the physician's communication style, the child's asthma symptoms, medical needs, and asthma care. Low income was defined as annual income of < 20,000 dollars.

MEASUREMENTS AND RESULTS

The families of 36 children (13%) had an income of < 20,000 dollars, and they were treated by 23 physicians. Low-income children in the treatment group tended to have higher levels of use of controller medications, to receive a written asthma action plan, and to miss fewer days of school, although these differences were not statistically significant compared to low-income children in the control group. However, low-income treatment group children were significantly less likely to be admitted to an emergency department (annual rate, 0.208 vs 1.441, respectively) or to a hospital (annual rate, 0 vs 0.029, respectively) for asthma care compared to children in the control group.

CONCLUSIONS

The educational program for physicians improved asthma outcomes for their low-income patients. Provider interventions targeted to these high-risk patients may diminish hospital and emergency department asthma care.