Volume 124, Issue 2 , Pages 381-383, August 2009
Does access to care equal asthma control in school-age children?
Article Outline
To the Editor:
In 2005, 6.5 million children under 18 years were documented as having asthma.1 Access to care is thought to be key to asthma control. The “medical home” is a concept that started for children with special needs but now has been extended to all individuals.2 Those with a medical home have fewer hospitalizations and emergency department visits.3 Likewise, in both adults and children, hospitalization rates and emergency care use have been shown to be higher in those with public or no insurance.4, 5, 6, 7, 8
This study sought to examine the relationship between access to care and asthma control for children within the Denver Public School Asthma Program, an outreach program in 19 (14 elementary and 5 middle) schools in the Northeast/Northwest sections of Denver. Of these students, 728 were identified as having asthma and were invited to participate. Approval was received from the National Jewish Health Institutional Review Board, and consent plus assent were obtained from all participants and caregivers. The children's demographic information and various measures of asthma control were compared according to the presence or absence of medical insurance or a medical provider by using the t test for continuous variables and the χ2 test for categorical data. In addition, for insurance or medical provider status, comparisons were analyzed according to the type of medical insurance (ie, public vs private) and the type of provider (ie, primary care vs specialty).
Demographic characteristics for the 155 students enrolled included a mean ± SD age of 9.2 ± 2.6 years, with 58% male, 25% black, and 51% Hispanic. The majority qualified for reduced lunch (79%), had health insurance (90%, of which 54% were public plans; Fig 1, A), and had a physician caring for their asthma (92%; Fig 1, B).
Fig 1.
A, 90% (139/155) of children had health care coverage, 54% public plans such as Colorado Health Services (CHS), Child Health Plan Plus (CHP), or Colorado Indigent Care Program (CICP). B, 94% (145/155) identified having a medical care provider that cared for their child's asthma. 89% (129/145) of those students with providers were managed by primary care providers (although not all parents knew if this was a pediatrician or family physician; undetermined, not know specialty; missing, not filled out; physician assistant/nurse practitioner, PA/NP).
Asthma control was similar, but overall poor, among students with vs without medical insurance: 30 vs 44% reported prednisone use in the past year (P = .3), 39 vs 50% had any hospitalization (P = .4), 57 vs 63% used emergency care (P = .6), 26 vs 33% reported frequent rescue inhaler use (P = .6), 30 vs 25% had persistent daytime symptoms (P = .7), and 32 vs 19% had persistent nighttime symptoms (P = .2). In general, low use of controller therapy was reported by children with or without medical insurance (30% vs 25%; P = .7); 20% were on inhaled corticosteroid monotherapy, 4% on a leukotriene receptor antagonist alone, and 4% on combination inhaled corticosteroid/leukotriene receptor antagonist or inhaled corticosteroid/long-acting β-agonist.
There was no difference between participants with public vs private insurance with regard to percentages with hospital admissions (P = .06), emergency department visits (P = .3), controller use (P = .7), uncontrolled daytime symptoms (P = .9), rescue inhaler use (P = .1), and uncontrolled nighttime symptoms (P = .6). However, more individuals with private insurance were likely to have required prednisone for asthma in the past year than those with public insurance (P = .02; Table I), and this observation could not be attributed to age, sex, or racial differences in children with private or public insurance.
Table I. Percentages of students who had no insurance, public health insurance, and private insurance as well as those without a primary health care provider, a primary care provider, or a specialist provider caring for their asthma with regard to demographics and several measures of asthma control
| Medical insurance | Medical provider | |||||
|---|---|---|---|---|---|---|
| None reported (n = 16) | Public (n = 82) | Private (n = 55) | None reported (n = 10) | Primary care (n = 129) | Specialty (n = 10)∗ | |
| Mean (SD) age (y) | 8.8 (2.1) | 9.1 (2.7) | 9.3 (2.7) | 10.6 (1.7) | 9.1 (2.6) | 8.5 (3.0) |
| Sex (% male) | 68.8 | 57.3 | 57.4 | 70.0 | 57.7 | 70 |
| Ethnicity (%) | ||||||
 Black | 12.5 | 24.7 | 29.1 | 10 | 26.3 | 20 |
| Hispanic | 68.8 | 58.0 | 32.7 | 80 | 48.8 | 30 |
| White | 12.5 | 2.5 | 29.1 | 0 | 12.4 | 40 |
| Percent qualifying for free lunch | 93.8 | 97.6 | 47.2 | 100 | 78.6 | 50 |
| Percent reporting daytime symptoms >2 times/wk | 25 | 29.5 | 30.2 | 18 | 31.2 | 40 |
| Percent reporting nighttime symptoms >1 time/wk | 18.8 | 34.2 | 29.6 | 20 | 30.7 | 60 |
| Percent reporting bronchodilator rescue use >2 times/wk | 33.3 | 31.3 | 18.9 | 12.5 | 27.9 | 44.4 |
| Percent reporting prednisone use in the past year | 43.8 | 22.2 | 41.5 | 11.1 | 29.5 | 80 |
| Percent reporting ever needing hospitalization | 50 | 45 | 29.1 | 25 | 39 | 60 |
| Percent reporting ever needing emergency care | 62.5 | 53.1 | 61.8 | 33.3 | 58 | 80 |
∗Of note, 4 individuals did not know specialty of physician and 2 left a blank response. |
Students with medical providers were as likely as those without an identified provider to report a hospitalization for asthma (41% vs 25%; P = .4), emergency care utilization (59% vs 33%; P = .1) regular inhaled corticosteroid (25% vs 20%; P = .7) or rescue inhaler use (28% vs 13%; P = .3), and uncontrolled nighttime symptoms (32% vs 20%; P = .4). There were differences in the percentages of participants reporting prednisone use the past year (33% vs 11%; P = .1) or uncontrolled daytime symptoms (31% vs 10%; P = .1), although the P values were marginal.
Similar percentages of students cared for by primary care providers versus specialists had any hospitalization (P = .2), emergency department visits (P = .2), uncontrolled daytime (P = .6) or nighttime symptoms (P = .06), and rescue bronchodilator use (P = .3). In contrast, a significant difference in the percentages between the 2 groups was found with respect to higher prednisone use in the past year for those treated by specialists (P = .002). There was a trend toward higher controller use in those treated by a specialist physician (P = .06), although the difference was not statistically significant.
Of note, black children were as likely to have insurance coverage and a medical provider compared with nonblack children. Most indicators of poor asthma control were similar between black and nonblack subjects—that is, comparable rates of steroid use in the past year (P = .95), history of hospitalization (P = .7) or emergency department visits (P = .4), daytime symptoms (P = .7), and bronchodilator rescue use (P = .1), except for a higher percentage of uncontrolled nighttime symptoms reported by black children (47% vs 27%; P = .02).
Therefore, in this study, 90% of students had medical insurance coverage, and 94% had accessibility to health providers, but there were still high percentages of students with uncontrolled asthma and no differences on the basis of type of insurance or practitioner. A possible explanation for this is that although a patient may have both insurance and a primary provider, the patient may not regularly seek care from that individual. If so, this is an especially important consideration in a disease such as pediatric asthma. Unlike other chronic diseases such as adult asthma or diabetes, pediatric asthma is a condition in which those affected often have completely asymptomatic periods between severe exacerbations. Not having the daily reminders of the disease would render one less likely to seek routine care during these periods until a crisis occurs. Thus, there would not be a regular opportunity for education and disease management. Another possible explanation is that even if a patient seeks regular medical care, asthma education is a time-consuming process, and extensive educational sessions may be difficult to implement in a busy outpatient practice.
Of interest was the finding that students with public insurance had lower rates of prednisone use than those without insurance or with private insurance. With such a finding, we wonder whether the prednisone was given more often to certain groups because of worsened disease or because of other factors such as concern for lack of follow-up. Also, more students with identified medical providers reported using emergency care compared with those without identified providers. It is possible that individuals with regular medical providers are more likely to seek medical care and treatment. For instance, asthma action plans typically recommend that the individual seek medical care in response to worsening asthma or poor asthma control. In addition, those who have more severe disease have the need to be followed closely by a physician. Similarly, a higher rate of steroid use in those children being treated by specialists compared with children followed by primary care providers was found, not surprising as these children are more likely to be referred to specialists.
Racial differences in asthma control were confirmed. Black subjects showed subtle evidence of poorer asthma control, having higher percentages of nighttime symptoms than nonblack subjects.
In conclusion, this study found that despite having access to care, there were still high percentages of children with uncontrolled asthma, indicating that children are in need of additional programs to identify, monitor, and educate those at high risk for asthma morbidity.
References
- Akinbami LJ. State of childhood asthma, United States, 1980-2005. 2006. National Center for Health Statistics Center for Disease Control. Available at: http://www.cdc.gov/nchs/pressroom/06facts/asthma1980-2005.htm. Accessed December 12, 2006.
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Supported by the Colorado Department of Public Health and Environment Cancer, Cardiovascular, and Pulmonary Disease Program as well as GlaxoSmithKline. Disclosure of potential conflict of interest: R. A. Covar is an advisor and consultant for Merck. M. Gleason has received research support from AstraZeneca, GlaxoSmithKline, Merck, Genentech, and the National Institutes of Health and is a member of Board of Directors of the Colorado Asthma Coalition. L. Cicutto has received research support from the Ontario Ministry of Health and Long Term Care, the Ontario Lung Association, AllerGen NCE, the National Institutes of Health, and GlaxoSmithKline. S. J. Szefler is a consultant for GlaxoSmithKline, Genentech, and Merck and has received research support from the National Institutes of Health, the National Heart, Lung, and Blood Institute, the National Institute of Allergy and Infectious Diseases, Ross Pharmaceuticals, and GlaxoSmithKline. The rest of the authors have declared that they have no conflict of interest.
PII: S0091-6749(09)00983-X
doi:10.1016/j.jaci.2009.05.048
© 2009 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Volume 124, Issue 2 , Pages 381-383, August 2009
