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Underuse of controller medications among Medicaid-insured children with asthma
Jonathan A Finkelstein1, Paula Lozano, Harold J Farber
1Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Ave, 6th Floor, Boston, MA 02215, USA. Jonathan_Finkelstein@harvardpilgrim.org
Insights
Asthma controller medication underuse is common in low-income children, especially among racial minorities and those with less educated parents. Improved care processes like action plans and specialist visits reduce this underuse.
Area of Science:
- Pediatric Pulmonology
- Health Services Research
- Public Health
Background:
- National guidelines advocate daily controller medication for children with persistent asthma.
- Underuse of controller medications is a known issue, particularly among low-income populations with high asthma burden.
- Predictors of controller medication underuse in this vulnerable group remain under-explored.
Purpose of the Study:
- To quantify controller medication underuse in Medicaid-insured children across various managed care settings.
- To identify demographic factors associated with controller medication underuse.
- To examine asthma care processes linked to controller medication underuse.
Main Methods:
- Cross-sectional telephone survey of parents of 1648 Medicaid-insured children (aged 2-16) with asthma.
- Assessed parent-reported controller medication underuse in children with persistent asthma.
- Utilized logistic regression to analyze associations between demographic factors, care processes, and underuse.
Main Results:
- 73% of children with persistent asthma were underusers of controller therapy.
- Black and Latino race were significantly associated with higher underuse rates.
- Higher parental education, primary care physician contact, written action plans, follow-up visits, and asthma specialist consultations were associated with lower underuse.
Conclusions:
- Widespread underuse of asthma controller medications exists among Medicaid-insured children.
- Racial minorities and children of less educated parents face elevated risks of underuse.
- Structured asthma care elements, including action plans and specialist involvement, mitigate underuse and associated symptoms.
Background:
National guidelines recommend daily use of controller medications for children with persistent asthma. Although studies suggest low rates of controller use, little is known about predictors of underuse among low-income children in whom asthma morbidity is greatest.
Objectives:
To determine the frequency of underuse of controller medications among Medicaid-insured children in a variety of managed care arrangements, and to examine demographic factors and processes of asthma care associated with underuse.
Design:
Cross-sectional telephone survey of parents of children and adolescents aged 2 to 16 years with asthma, insured by Medicaid, and enrolled in 1 of 5 managed care plans. The main outcome was parent-reported underuse of controllers among children with persistent asthma. Survey items included demographic factors and reports of specific processes of care. Current symptom level was determined by recall of the number of days with symptoms in the previous 14 and by the Physical Function Score of the American Academy of Pediatrics (AAP) Child Health Status Assessment for Asthma. Logistic regression was used to identify factors independently associated with underuse.
Results:
The response rate was 66%, with 1648 children included in the analysis; 1083 were classified as having persistent asthma. Of these, 73% were underusers of controller therapy, with 49% reporting no controller use and 24% reporting less than daily use. A multivariate model that adjusted for age, managed health care organization, and AAP Physical Function Score found that black (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.4) or Latino (OR, 2.2; 95% CI, 1.3-3.8) race were associated with underuse and that parental education beyond high school was protective (OR, 0.6; 95% CI, 0.4-0.8). Having a primary care physician (OR, 0.4; 95% CI, 0.2-0.8), written action plan (OR, 0.5; 95% CI, 0.4-0.7), or a follow-up visit (OR, 0.5; 95% CI, 0.4-0.8) and having seen an asthma specialist (OR, 0.5; 95% CI, 0.4-0.7) were associated with lower rates of underuse.
Conclusions:
Underuse of controller medications among Medicaid-insured children is widespread. Racial minorities and children whose parents are less educated are at higher risk for underuse. Patients who have received action plans or had follow-up visits or specialty consultations are less likely to be symptomatic underusers of controller medications.