Harold J. Farber

Misunderstanding of Asthma Controller Medications: Association with Nonadherence

Objective. Nonadherence to regular inhaled anti-inflammatory medication use is a frequent contributor to poor control of persistent asthma and may result from misunderstanding of the preventive role of such medications. This studys aims are to 1) test the hypothesis that misunderstanding is associated with decreased adherence to its daily use and 2) identify factors associated with increased risk of misunderstanding. Study Design. A sample of parents of children with asthma insured by Medicaid and enrolled in managed care programs in Northern California, Washington, and Massachusetts were interviewed by telephone. This analysis focused on the subset that reported having an inhaled anti-inflammatory medication and whose medication use and symptom frequency in the 2 weeks before the interview suggested persistent asthma. Misunderstanding of the role of inhaled anti-inflammatory medication was defined as identifying it as being for treatment of symptoms after they begin and not for prevention of symptoms before they start. Results. A total of 1663 parents of children with asthma (63% response rate) were interviewed. Of those, 571 subjects (34%) reported use of an inhaled anti-inflammatory medication and met our criteria for persistent asthma. Among those with persistent asthma, 23% (131 parents) misunderstood the role of their childs inhaled anti-inflammatory. Misunderstanding of inhaled anti-inflammatory medication was associated with decreased adherence to its daily use (odds ratio [OR] 0.18, 95% confidence interval [CI], 0.11–0.29). The risk for misunderstanding was lower if the patient had seen a specialist (OR 0.42, 95% CI, 0.24–0.75) or had graduated high school (OR = 0.54, 95% CI, 0.34–0.84). Conclusion. Misunderstanding of the role of inhaled anti-inflammatory medication is associated with reduced adherence to its daily use.

Risk of Readmission to Hospital for Pediatric Asthma

To describe risk for hospital readmission for pediatric asthma occurring within 12 months of index hospital admission, we reviewed the medical records of all pediatric (age < 15 years) patients admitted for asthma to the Kaiser Foundation Hospital (KFH), Hayward, California, between September 30, 1991 and June 30, 1993. Patients aged < 5 years or who had a history of prior hospital admission were at high risk for hospital readmission within 12 months of the index admission. A single-session asthma class did not reduce risk for hospital readmission.

Protecting Children From Tobacco, Nicotine, and Tobacco Smoke.

This technical report serves to provide the evidence base for the American Academy of Pediatrics’ policy statements “Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke” and “Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke.” Tobacco use and involuntary exposure are major preventable causes of morbidity and premature mortality in adults and children. Tobacco dependence almost always starts in childhood or adolescence. Electronic nicotine delivery systems are rapidly gaining popularity among youth, and their significant harms are being documented. In utero tobacco smoke exposure, in addition to increasing the risk of preterm birth, low birth weight, stillbirth, placental abruption, and sudden infant death, has been found to increase the risk of obesity and neurodevelopmental disorders. Actions by pediatricians can help to reduce children’s risk of developing tobacco dependence and reduce children’s involuntary tobacco smoke exposure. Public policy actions to protect children from tobacco are essential to reduce the toll that the tobacco epidemic takes on our children.

Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke.

Tobacco dependence starts in childhood. Tobacco exposure of children is common and causes illness and premature death in children and adults, with adverse effects starting in the womb. There is no safe level of tobacco smoke exposure. Pediatricians should screen for use of tobacco and other nicotine delivery devices and provide anticipatory guidance to prevent smoking initiation and reduce tobacco smoke exposure. Pediatricians need to be aware of the different nicotine delivery systems marketed and available. Parents and caregivers are important sources of children’s tobacco smoke exposure. Because tobacco dependence is a severe addiction, to protect children’s health, caregiver tobacco dependence treatment should be offered or referral for treatment should be provided (such as referral to the national smoker’s quitline at 1-800-QUIT-NOW). If the source of tobacco exposure cannot be eliminated, counseling about reducing exposure to children should be provided. Health care delivery systems should facilitate the effective prevention, identification, and treatment of tobacco dependence in children and adolescents, their parents, and other caregivers. Health care facilities should protect children from tobacco smoke exposure and tobacco promotion. Tobacco dependence prevention and treatment should be part of medical education, with knowledge assessed as part of board certification examinations.

Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke.

Tobacco use and tobacco smoke exposure are among the most important health threats to children, adolescents, and adults. There is no safe level of tobacco smoke exposure. The developing brains of children and adolescents are particularly vulnerable to the development of tobacco and nicotine dependence. Tobacco is unique among consumer products in that it causes disease and death when used exactly as intended. Tobacco continues to be heavily promoted to children and young adults. Flavored and alternative tobacco products, including little cigars, chewing tobacco, and electronic nicotine delivery systems are gaining popularity among youth. This statement describes important evidence-based public policy actions that, when implemented, will reduce tobacco product use and tobacco smoke exposure among youth and, by doing so, improve the health of children and young adults.

Health Plan Employer Data and Information Set (HEDIS®) Criteria to Determine the Quality of Asthma Care in Children

The Health Plan Employer Data and Information Set (HEDIS®) of the National Committee for Quality Assurance is a set of standardized performance measures, the goal of which is to enable purchasers and consumers to evaluate the quality of different health plans. The HEDIS® ‘Use of Appropriate Medications for People with Asthma’ measure assesses the presence of an asthma controller medication dispensing in patients who meet healthcare utilization criteria that suggest persistent asthma. The HEDIS® asthma measure has been criticized on the basis of poor sensitivity and specificity for identifying persistent asthma because just one asthma controller medication dispensing is unlikely to be effective, and because asthma controller medications are not all the same.Meeting the HEDIS® criteria may be associated with reductions in asthma crisis care in more adherent population groups; however, in less adherent populations, a paradoxical increase in asthma crisis care has been observed. The ‘asthma medication ratio’ of anti-inflammatory divided by (anti-inflammatory plus bronchodi-lator) canister dispensings has been proposed as an alternative quality-of-care measure, and improvements in the ratio are associated with a reduction in asthma crises. However, this measure has been criticized because of the difficulty in determining dose equivalence among various medications and delivery systems. Medication-based measures of asthma care quality, although associated with clinically important outcomes, may also create adverse incentives for overtreatment. In addition, medication-based measures only assess the level of asthma control indirectly and neglect important parameters of asthma care, including identification and control of asthma triggers, stepping down medication when asthma is well controlled, and the development of a patient/doctor partnership. Although there is utility to medication-based measures of asthma care quality, we need to be cognizant of the limitations of medication-based measures.Many items that affect asthma control, such as air quality, housing quality, and involuntary smoke exposure, reflect choices of our society. From a societal perspective, quality of care for the uninsured/intermittently insured is as important as for the continuously enrolled. Asthma control reflects not only the quality of medical care delivered, but also broader aspects of the health of our society. Perhaps the future of asthma quality assessment is not just about physician and health plan performance but also about the performance of our communities and nations in protecting the respiratory health of the most vulnerable.

Combination Therapy for Asthma: Perspectives of the Patient, Provider, and Payer

As treatment for moderate to severe persistent asthma, inhaled corticosteroid drugs combined with long-acting β-adrenoceptor agonists are being marketed in a single inhaler device. These combination products have important benefits (e.g. convenience, improved adherence, and improved day-to-day asthma symptom control); however, there are also problems (e.g. risk of severe asthma flares associated with long-acting β-adrenoceptor agonist therapy, high price of combination inhalers, and limited ability to titrate the dose of each component independently). Combination therapy is most likely to benefit patients with moderate to severe persistent asthma whose disease is not controlled on inhaled corticosteroids alone. Some patients may prefer this combination product to inhaled corticosteroids plus a leukotriene modifier or theophylline. For other patients with moderate to severe persistent asthma, inhaled corticosteroid adherence may be improved by use of the combination product. Combination long-acting β-adrenoceptor agonist/inhaled corticosteroid therapy is not appropriate for patients with predominantly exercise-induced asthma, patients unable to use the inhaler device, patients with either mild intermittent or mild persistent asthma, and patients whose asthma can be controlled on a low to moderate dose of inhaled corticosteroid medication alone.As currently priced, combination long-acting β-adrenoceptor agonist/inhaled corticosteroid therapy leads to increased costs compared with inhaled corticosteroids alone; however, in appropriately selected patients, this cost is offset by improvements in asthma symptoms and lung function. Some patients may value increases in symptom-free days, convenience, and a less offensive taste (especially with a dry-powder inhaler delivery system). Others may prefer drug minimization and/or may prefer metered-dose inhaler or nebulizer delivery systems. Providers need to be able to match the medication to the medical needs and preferences of the patient/family as best as possible. Providers need to be able to educate the patient and/or parents on the role of the medication, expected results, and inhalation techniques. Inappropriate use of combination therapy, such as for individuals with only mild asthma whose asthma can be controlled on simpler therapy, should be avoided. Health plans are accountable for both quality and costs of care. They are interested in restricting inappropriate use of combination therapy.

Author’s Response: On Careful Reanalysis of Our Findings I Stand by Our Results and Interpretation

In the comment by Dr Tripepi, “Alternative Explanation of the Results,” I respectfully disagree with assertions that we misinterpreted our findings. Our specific aim was to determine the different effects of palivizumab on hospitalizations with an RSV diagnosis and hospitalizations without an RSV diagnosis. We clearly showed differences and a dose–response effect.1 It appears Dr Tripepi would like an analysis of pooled hospitalization rates (hospitalization with RSV diagnosis plus hospitalization for bronchiolitis without an RSV diagnosis) for infants born at 29 to 32 weeks’ gestation to determine whether there is a net benefit or harm. When we sum RSV and non-RSV hospitalizations … E-mail: hjfarber{at}texaschildrens.org

Author’s Response: One Should Not Dismiss Our Findings as “Just Statistics”

Dr Boyce’s group criticizes our study as biased on “confounding by indication” and states that therefore results should be dismissed. Because 41.5% of the otherwise healthy infants born at 29- to 32-weeks’ gestation in our population received ≥1 doses of palivizumab, a very large proportion of this population is represented. To decrease risk of confounding by indication, we carefully excluded infants who had claims suggesting a significant chronic illness that could affect risk for severe RSV disease. The full list of exclusion criteria was published in the Supplemental Materials. To reduce variation by socioeconomic status, our data set was restricted to a Medicaid-insured population. Variation by age group at start of RSV season was accounted for in our multivariate analyses. Furthermore, in the 29- to 32-week age group this variation was small, with only a 17-day difference in mean age between those who received ≥1 palivizumab doses and … E-mail: hjfarber{at}texaschildrens.org