James H. Glauber

Asthma Care Quality for Children With Minority-Serving Providers

OBJECTIVE To compare asthma care quality for children with and without minority-serving providers. DESIGN Cross-sectional telephone survey of parents, linked with a mailed survey of their childrens providers. SETTING A Medicaid-predominant health plan and multispecialty provider group in Massachusetts. PARTICIPANTS A total of 563 children with persistent asthma, identified by claims and encounter data. Main Exposure Whether the childs provider was minority serving (>25% of patients black or Latino). Outcomes Parent report of whether the child had (1) ever received inhaled steroids, (2) received influenza vaccination during the past season, and (3) received an asthma action plan in the past year. RESULTS In unadjusted analyses, Latino children and those with minority-serving providers were more likely to have never received inhaled steroids. In adjusted models, the odds of never receiving inhaled steroids were not statistically significantly different for children with minority-serving providers (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.63-2.64), or for Latino vs white children (OR, 1.76; 95% CI, 0.74-4.18); odds were increased for children receiving care in community health centers (OR, 4.88; 95% CI, 1.70-14.02) or hospital clinics (OR, 4.53; 95% CI, 1.09-18.92) vs multispecialty practices. Such differences were not seen for influenza vaccinations or action plans. CONCLUSIONS Children with persistent asthma are less likely to receive inhaled steroids if they receive care in community health centers or hospital clinics. Practice setting mediated initially observed disparities in inhaled steroid use by Latino children and those with minority-serving providers. No differences by race/ethnicity or minority-serving provider were observed for influenza vaccinations or asthma action plans.

Stratifying asthma populations by medication use: how you count counts

BACKGROUND Asthma disease management programs typically use pharmacy data to identify high-risk individuals for outreach. Provider-directed pharmacy profiling seeks to identify physicians whose prescribing of recommended asthma medication is suboptimal. Both strategies require an accurate approach to counting prescribed asthma medication. OBJECTIVE We compare two methods for counting the use of bronchodilators and inhaled anti-inflammatory medication. One approach uses simple counts of dispensed medication. An alternative, canister-equivalent method standardizes these medications on the basis of variation in both potency and medication-days supplied per prescription. We evaluate whether these alternative methods yield different population risk profiles when applied to managed care enrollees who have asthma and to the physicians treating them. METHODS Retrospective cohort study of patterns of medication use by asthmatic patients receiving care within a group-model health maintenance organization and prescribing of asthma medications by the physicians treating them. RESULTS Each method yields a different risk profile of the patient and physician populations, respectively. Relative to simple counts, the canister-equivalent method results in a 40% increase in the population identified as having high bronchodilator use and chronic anti-inflammatory medication use. On the physician-level, the mean anti-inflammatory:bronchodilator ratio (AIF:BD) was 1.50 by the canister-equivalent method compared with 1.08 by the simple-count method. When stratified by each method, 36% of physicians were assigned to different quartiles of anti-inflammatory:bronchodilator ratio. CONCLUSIONS A novel canister-equivalent method for counting dispensed asthma medications yields different risk profiles compared with simple counts of asthma medications. Asthma disease management programs should consider alternative approaches to improve the accuracy of risk profiling based on patterns of medication use.

Asthma self-assessment in a Medicaid population

BackgroundSelf-assessment of symptoms by patients with chronic conditions is an important element of disease management. A recent study in a commercially-insured population found that patients who received automated telephone calls for asthma self-assessment felt they benefitted from the calls. Few studies have evaluated the effectiveness of disease self-assessment in Medicaid populations. The goals of this study were to: (1) assess the feasibility of asthma self-assessment in a population predominantly insured by Medicaid, (2) study whether adding a gift card incentive increased completion of the self-assessment survey, and (3) evaluate how the self-assessment affected processes and outcomes of care.MethodsWe studied adults and children aged 4 years and older who were insured by a Medicaid-focused managed care organization (MCO) in a pre- and post-intervention study. During the pre-incentive period, patients with computerized utilization data that met specific criteria for problematic asthma control were mailed the Asthma Control Test (ACT), a self-assessment survey, and asked to return it to the MCO. During the intervention period, patients were offered a

Outcomes After Periodic Use of Inhaled Corticosteroids in Children

20 gift card for returning the completed ACT to the MCO. To evaluate clinical outcomes, we used computerized claims data to assess the number of hospitalization visits and emergency department visits experienced in the 3 months after receiving the ACT. To evaluate whether the self-management intervention improved processes of care, we conducted telephone interviews with patients who returned or did not return the ACT by mail.ResultsDuring the pre-incentive period, 1183 patients were identified as having problems with asthma control; 25 (2.0%) of these returned the ACT to the MCO. In contrast, during the incentive period, 1612 patients were identified as having problems with asthma control and 87 (5.4%) of these returned the ACT to the MCO (p < 0.0001). Of all 95 ACTs that were returned, 87% had a score of 19 or less, which suggested poor asthma control.During the 3 months after they received the ACT, patients who completed it had similar numbers of outpatient visits, emergency department visits, and hospitalizations for asthma as patients who did not complete the ACT. We completed interviews with 95 patients, including 28 who had completed the ACT and 67 who had not. Based on an ACT administered at the time of the interview, patients who had previously returned the ACT to the MCO had asthma control similar to those who had not (mean scores of 14.2 vs. 14.6, p = 0.70). Patients had similar rates of contacting their providers within the past 2 months whether they had completed the mailed ACT or not (71% vs. 76%, p = 0.57).ConclusionMailing asthma self-assessment surveys to patients with poorly controlled asthma was not associated with better asthma-associated outcomes or processes of care in the Medicaid population studied. Adding a gift card incentive did not meaningfully increase response rates. Asthma disease management programs for Medicaid populations will most likely need to involve alternative strategies for engaging patients and their providers in managing their conditions.

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

Background. Many children with persistent asthma use inhaled corticosteroids on a periodic basis. Clinical trials in adults suggest that periodic use of inhaled corticosteroids may be effective for patients with mild persistent asthma. However, scant information exists on the clinical outcomes of children with asthma who are using inhaled corticosteroids on a periodic basis in real-world settings. Objective. This prospective cohort study compared clinical outcomes during a 12-month follow-up period between children with persistent asthma whose parents believed that they were supposed to use inhaled steroids either (a) periodically or (b) daily year-round at the start of the period. The clinical outcomes studied were (1) asthma-related emergency department (ED) visits or hospitalizations, (2) uncontrolled asthma based on health care and medication use, and (3) outpatient visits for asthma. Patients and methods. The study population included children with persistent asthma from two health plans whose parents reported that they were using inhaled corticosteroids during a baseline telephone interview. The interviews collected information on whether the childrens parents believed they were supposed to use inhaled corticosteroids on a periodic or daily basis, as well as baseline asthma symptom status, sociodemographic, and behavioral variables. We used computerized databases to identify clinical events for each child during the 12 months after their baseline interview. Uncontrolled asthma was defined as any asthma-related ED visit or hospitalization, two or more oral steroid prescription fills, or four or more beta-agonists canisters filled during the 12-month period. We compared these outcomes between the periodic versus daily users of inhaled corticosteroids using logistic regression analyses. We conducted both (1) a traditional logistic regression analysis in which we adjusted for selection bias by including covariates such as age, asthma physical status, sociodemographic and behavioral variables, and history of asthma-related health care use during the year before interview and (2) an analysis using propensity scores to more fully adjust for selection bias. Results. Of a total of 476 children in the study, 55% of parents believed their children were supposed to be using inhaled corticosteroids on a periodic basis and 45% believed their children were supposed to be using them daily year-round based on the baseline parent interview. At baseline, periodic inhaled corticosteroid users had less severe asthma than daily users based on several measures including better asthma physical status scores on the Childrens Health Survey for Asthma (mean 87 ± 16.0 vs. 81 ± 17.4, p = < 0.0001). During the year before the baseline interview, periodic users compared with daily users were less likely to have an ED visit or hospitalization (10% vs. 23%, p = 0.0001) and less likely to have had five or more albuterol prescription fills (13% vs. 31%, p < 0.0001). During the follow-up year, those who believed inhaled steroids were for periodic use were less likely than those who believed inhaled steroids were for daily use to have an ED visit or hospitalization for asthma (OR 0.36, 95% CI: 0.18–0.73), even after adjusting for baseline asthma status and other covariates. Similarly, those who believed inhaled steroids were for periodic use were less likely to have uncontrolled asthma, OR 0.38 (95% CI: 0.24–0.62). Analyses using propensity score adjustment yielded similar results to the logistic regression analyses. Conclusion. Children whose parents believed they were supposed to use inhaled corticosteroids on a periodic basis had less severe asthma at baseline than those whose parents believed they were supposed to be using them daily. Periodic users were less likely than daily users to have adverse asthma outcomes during 1-year follow-up. This suggests that clinicians may be applying appropriate selection criteria by choosing patients with less severe asthma for periodic inhaled corticosteroid regimens.

Effects of Vaccine Information Pamphlets on Parents' Attitudes

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.