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* Health Policy Institute, Georgetown Public Policy Institute, Georgetown University, Washington, DC
Center for Healthcare Studies and Department of Internal Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
Midwest Center for Health Services and Policy Research, Hines Veteran Affairs Medical Center, Hines, Illinois
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Design. Retrospective cohort study using Medicaid claims data to analyze the process of asthma care in 1994, including all white (non-Hispanic), black (non-Hispanic), and Hispanic children (aged 2–18 years) with asthma in the non-health maintenance organization portion of the Massachusetts Medicaid program (N = 5773). Main outcome measures included performance on 6 claims-based process-of-care measures that reflect national guidelines. Measures addressed primary and specialty care for asthma, appropriate asthma pharmacotherapy, and timely follow-up care after asthma emergency department (ED) visits and hospitalizations.
Results. Controlling for case mix, provider type, disability status, age, and gender, Hispanic children with asthma were 39% less likely than white children to have a specialist visit for asthma (odds ratio [OR]: 0.61; confidence interval [CI]: 0.46–0.81) and 41% less likely to receive a follow-up visit within 5 days of being seen in the ED for asthma (OR: 0.59; CI: 0.36–0.95). However, Hispanic children received better care in 2 respects. They were 16% more likely than white children to receive a minimum of 2 asthma visits per year (CI: 1.01–1.34) and 27% less likely to be overprescribed ß-agonist medications (OR: 0.73; CI: 0.54–0.99). Black children were 64% less likely than white children to receive timely follow-up care after being seen in the ED for asthma (OR: 0.36; CI: 0.18–0.73). There were no racial/ethnic differences in the prescribing of antiinflammatory medications or timely follow-up care after an asthma hospitalization.
Conclusions. This study demonstrates important differences in the process of care experienced by racial/ethnic subpopulations within a Medicaid population, which may help explain differential outcomes. Efforts to improve asthma outcomes should target specific areas in which black and Hispanic children may be receiving suboptimal care.
Key Words: racial disparities • process of care • quality of care • Medicaid • pediatric asthma • guidelines
Abbreviations: ED, emergency department • PCCM, primary care case manager • ADG, ambulatory diagnostic group • NCQA, National Committee for Quality Assurance • NAEPP, National Asthma Education and Prevention Program • ANOVA, analysis of variance • CHC, community health center • OPD, outpatient hospital department • CI, confidence interval • OR, odds ratio
Numerous studies have documented significant racial/ethnic differences in asthma hospitalization rates1–4 and asthma emergency department (ED) visits,2,4 after controlling for income, insurance status, and other socioeconomic factors. Asthma hospitalization rates are also on the rise for both black and Hispanic children. Between 1985 and 1993, asthma hospitalizations increased 6.8% per year among Hispanic children and 4.5% among African American children but decreased 0.9% among white, non-Hispanic children.5 According to the most recent data available, hospitalization rates increased 25% for black children and 11% for white children from 1980 to 1999.6 Few studies have examined racial/ethnic differences in the process of care received by children with asthma from a relatively homogeneous socioeconomic background across provider settings.7–9
Efforts to improve asthma care have been spurred by the promulgation of clinical guidelines10,11 and the widespread implementation of quality-improvement initiatives,12,13 although low guideline adherence among physicians has been reported in several studies,14–17 and significant racial disparities persist. This study examines differences in the process of care received by a cohort of white, black, and Hispanic children with similar socioeconomic backgrounds, specifically, Medicaid-insured children in a single state program. Racial/ethnic variations in asthma care are characterized by the process of care in 4 key domains: regular primary care visits for asthma, appropriate asthma pharmacotherapy, access to asthma specialists, and timely follow-up care after an asthma hospitalization or ED event.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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76% of the state’s nonelderly Medicaid population); and were identified by their parents as being white (non-Hispanic), black (non-Hispanic), or Hispanic. The final study population included 5773 children. Data sources used in this analysis included Massachusetts Medicaid claims and demographic and managed care enrollment files. Differences in the underlying overall morbidity and health care needs among the 3 study groups were measured by using the Johns Hopkins Case-Mix System (Version 4.0).19 All regressions included 2 variables that summarized the total number of pediatric major ambulatory diagnostic groups (ADGs), of which there are 8, and pediatric minor ADGs, of which there are 16, assigned to each child. ADGs are the clinical building blocks of the Johns Hopkins Case-Mix System.19 The relative burden of asthma across study groups was measured by using the National Committee for Quality Assurance (NCQA) claims-based algorithm for identifying children likely to have persistent asthma.20 All case-mix variables were based on 1993 data, whereas the analysis of the process of care was conducted using 1994 data.
Measure Development
Processes of care were assessed using claims-based measures that reflect key aspects of care recommended in the 1991 National Asthma Education and Prevention Program (NAEPP) guidelines promulgated by the National Heart, Lung, and Blood Institute.10,11 These were the most current national guidelines in place during the study period (1994). Each measure reflects a key dimension of pediatric asthma care that could be captured in claims-level data (Fig 1). For each measure, an applicable (denominator) population was specified, as well as the recommended care item (numerator). The first 5 measures reflect recommended care and are positive in nature, whereas the last measure addresses overuse of ß-agonist medications. The first measure addresses routine primary care visits for asthma. Even among patients who have established control of their asthma, the guidelines recommend regular follow-up visits at 1- to 3-month intervals to review patients’ treatment plans, medications, and asthma-management techniques.10 The clinical rationale for such regular visits is that routine primary care will facilitate successful asthma management and thus reduce the likelihood of adverse events such as asthma ED visits or hospitalizations. For the purpose of identifying the denominator population for measure 2 (access to asthma specialists), we used the NCQA claims-based algorithm for identifying children with persistent asthma20 as the denominator population in comparing the relative access to specialists among the 3 study groups. For measures assessing timely follow-up care after an asthma ED visit or hospitalization, we examined that proportion of children receiving a follow-up physician visit within 5 days of being seen in the ED or discharged from the hospital for asthma. The NAEPP guidelines recommend that follow-up medical appointments should be made before the patient is discharged and that patients be assessed within 48 to 72 hours.10 Measures 3 and 6 address appropriate asthma pharmacology. For these measures, 1 months’ supply of ß-agonist medication was calculated by disaggregating (by grams of medication) prescriptions for aerosol, syrup, or nebulizer forms of ß-agonist into standardized units approximating a 1-month supply. These 3 forms of medication accounted for 98% of all ß-agonist prescriptions. For measures where a child might have multiple qualifying events, such as an asthma ED visit, analyses are based on the child’s first event only. Additional details on the clinical rationale and construction of these measures are available elsewhere.21–23
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2 tests and analyses of variance (ANOVAs) were used for descriptive analyses of racial/ethnic differences in asthma-related utilization, as appropriate. For analyses of the process of care, separate logistic regressions were performed for each measure, including only those children who met the denominator criteria for that measure, and including covariates suggested by the literature. In addition to demographic and case-mix variables, a region variable denoting Medicaid service areas was used to control for geographic differences in the quality of housing stock, availability of public transportation to medical facilities, concentration of health care providers and facilities, and other factors that may affect asthma care and outcomes. |
RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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With respect to differences in asthma morbidity and overall case mix, significantly more black children (67.4%) met the NCQA claims-based definition for persistent asthma relative to other groups (P < .05), with 63.7% of children overall meeting this criterion (Table 3). In examining prior asthma utilization, nearly 20% of black children had experienced an asthma ED visit or hospitalization in the previous year, compared with only 11% of white children and 13% of Hispanic children (P < .001). Both white and black children had an average number of 0.19 pediatric major ADGs, whereas Hispanic children averaged only 0.13 major pediatric illnesses annually (P < .001). White children had significantly more pediatric minor ADGs relative to black and Hispanic children (P < .001).
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1 asthma ED visits during the year.
Measuring the Process of Care
The question arises whether racial/ethnic differences documented with respect to adverse events are reflected also in the process of care children received. Table 4 summarizes bivariate analyses of the 6 process-of-care measures for children in the 3 study groups. Table 5 summarizes results of multivariate analyses, described below.
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Measure 2: Access to Asthma Specialists
Among the 3676 (63.7%) children who met the NCQA criteria for persistent asthma, only 12% received a visit with an asthma specialist during the year. Hispanic children with persistent asthma according to this definition were 39% less likely than white children with persistent asthma to receive a specialist visit with an allergist or pulmonologist at any time during the year (odds ratio [OR[: 0.61; CI: 0.46–0.81; P < .001). Black and white children had similar utilization of asthma specialists.
Measure 3: Use of Antiinflammatory Medications
As seen in the crude rates for measure 3, 65.1% of children who received at least 3 prescriptions for ß-agonists during a 6-month period also received a prescription for antiinflammatory medication during the same period, with rates among the 3 groups ranging from 60% to 67%. There were no racial/ethnic differences in the rates of filled prescriptions for antiinflammatory medications after controlling for case mix, age, gender, provider type, and region.
Measure 4: Timely Follow-up Care After an Asthma ED Visit
Among the 801 children (13.9%) who had at least 1 asthma ED visit, only 118 (14.7%) received a follow-up visit within 5 days of being seen in the ED for asthma. Controlling for case mix, age, gender, provider type, and region, Hispanic children were 41% less likely than white children to receive timely follow-up care (OR: 0.59; CI: 0.36–0.95; P < .05), and black children were 64% less likely than white children to receive such care (OR: 0.36; CI: 0.18–0.73; P < .01).
Measure 5: Timely Follow-up Care After Hospitalization for Asthma
Measure 5 required that children hospitalized for asthma receive a follow-up physician visit within 5 days of discharge from the hospital. Of the 286 children (5%) hospitalized for asthma during the year, only 30% received a follow-up physician visit within 5 days of discharge. Only 25% of black children received such timely follow-up care, compared with 30% of white and Hispanic children. There were no significant differences across racial/ethnic groups after controlling for covariates.
Measure 6: Overreliance on ß-Agonist Medication
Measure 6 addresses overreliance on ß-agonist medication, defined as a child receiving >6 months supply of ß-agonist medication within a 6-month period. Overall, <8% of children in the study population received excessive amounts of ß-agonist medication. Black children were no more likely than white children to receive excessive amounts of ß-agonist medication. However, Hispanic children were 27% less likely than white children to have had levels of ß-agonist prescriptions indicating overuse (OR: 0.73; CI: 0.54–0.99; P < .05).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In analyzing racial/ethnic differences in the process of care received, there were several aspects of recommended asthma care in which black and Hispanic children served in the non-health maintenance organization portion of the Massachusetts Medicaid program received comparable care (and in some cases clinical care more consistent with national guidelines) than their white counterparts. All children in this statewide analysis received similar levels of antiinflammatory medication and were equally likely to receive a timely follow-up visit with a physician after an asthma hospitalization, after controlling for a range of factors. Black children were no more likely than white children to receive excessive amounts of ß-agonist medication, and Hispanic children were significantly less likely than white children to receive excessive amounts of ß-agonist medication. Massachusetts Medicaid providers were also successful in closing the racial/ethnic gap in primary care visits for children with asthma. Data from the National Health Interview Survey indicate that both black and Hispanic children with chronic illnesses receive fewer physician visits each year relative to white children. Black children nationally averaged 3.4 physician visits per year, Hispanic children 3.9 visits per year, and white children 5.2 visits per year.24 Similar disparities in primary care visits for conditions other than asthma were present in this cohort. In this study, however, there was no racial/ethnic gap in primary care visits for asthma. The proportion of children receiving at least 2 primary care visits for asthma per year were equal to and, in the case of Hispanic children, higher than that of white children.
There were significant racial/ethnic disparities, however, in 2 important areas: access to asthma specialty care and timely follow-up care after being seen in the ED for asthma. Specifically, Hispanic children with persistent asthma experienced significantly reduced access to asthma specialists, controlling for a range of important factors. This contradicts a recent study of Medicaid-insured children in 5 managed care organizations, in which Hispanic/Latino children were more likely than both white and black children to have had an asthma specialist visit in the past 6 months, controlling for demographic variables and asthma status.9 Although Hispanic children had reduced access to asthma specialty care, they did not experience excessive asthma hospitalizations, suggesting a possible substitution effect of regular primary care visits in lieu of specialty care with no adverse impact on hospitalization rates. After controlling for a number of factors, Hispanic children in this study, however, were 56% more likely than white children to be seen in the ED for asthma. In this study, we used the NCQA definition for persistent asthma for purposes of comparing the relative access to specialty care among children with asthma. This represents a fairly low threshold for referral to an asthma specialist. Additional study of the impact of access to specialty care among Hispanic children with more severe asthma on hospitalizations and ED visits is an area for future research.
The second area in which significant racial/ethnic disparities were identified was in the timeliness of follow-up care after an asthma ED visit. Black and Hispanic children were not only more likely to be seen in the ED but also were less likely to receive timely follow-up care after an asthma ED event. Only 7% of black children and only 13% of Hispanic children seen in the ED for asthma had a follow-up physician visit within 5 days of discharge from the ED, compared with 20% of white children. Significant disparities persisted after controlling for health status, disability status, provider type, region, age, and gender.
These results highlight longstanding patterns of high rates of ED utilization among minority children with asthma. Several studies have documented higher asthma ED usage among black children in particular, with race differentials persisting across all income levels.25 Halfon et al26 found black race, lower educational levels, and urban setting all to be risk factors for higher ED usage regardless of insurance status or health care need. A study of children in the Michigan Medicaid program found that black children were 70% more likely than white children to be seen in the ED, controlling for provider type and other covariates.2 Other studies of low-income, inner-city populations report that as many as 40% to 58% of African American children rely on EDs as their usual source of asthma care.27,28 Asthma is the second leading cause of ED visits nationally among adolescents,29 with black teens accounting for a disproportionate number of ED visits relative to white teens.29,30
Also of interest is the low use of physician offices among minority patients. Weitzman et al31 found that African American children nationwide used physician offices as their usual source of care only 40% as often as white children and used EDs 3 times as often as their white counterparts. A recent analysis of National Health Interview Survey data found both Hispanic ethnicity and black race to be independent predictors of not having seen a physician in the past year—more powerful predictors than either poverty or parental education.32 Even among middle-class children with private insurance, black children have been found to have fewer physician visits, be less likely to receive their care in a physician’s office, be less likely to have continuity of care, and be 3 times as likely to use EDs as white children,31 suggesting an independent effect of race on ED usage.
Reducing asthma ED visits among minority children is an important challenge for Medicaid programs, with implications for both program costs and quality of life for affected families. Black children identified as high ED users in 1 year are nearly twice as likely to be similarly high users the following year relative to their peers,33 emphasizing the importance of understanding the needs and preferences of these families. Additional research is needed to understand the dynamics underlying reliance on the ED for asthma care among black children in particular. Available data are inconsistent and incomplete. Some preliminary data from interviews with black parents of children with asthma suggest that many parents view EDs as providing superior care, whereas others see asthma exacerbations as an emergency situation.34 Minority children may also experience greater barriers in accessing care outside the hospital setting. In a study of 25 primary care clinics serving 7 inner-city areas, for example, >50% of children seen in the ED reported difficulty obtaining follow-up care after leaving the hospital.35 A differential experience of the responsiveness of the health care system to families’ needs may also play a role. A recent national study, for example, found poor, minority, and uninsured children nearly twice as likely to wait 60 minutes to be seen by a physician at their sites of care.36
Unlike 2 recent studies by Ortega et al37 and Lieu et al,9 which found both black and Hispanic children to be significantly less likely to receive inhaled steroid medication relative to white children after controlling for a number of demographic and asthma status variables, we did not find that racial/ethnic differences in antiinflammatory use persisted after controlling for the effect of other covariates. We did, however, find low antiinflammatory use among the entire study cohort. Even among children in our study group who received 3 months’ supply of ß-agonist medication within a 6-month period (<18% of the study population), only 65% also received an antiinflammatory medication within the same time frame.
Previous studies have documented low rates of antiinflammatory medication among Medicaid and inner-city populations, with rates varying widely depending on how the denominator population was defined. Studies of inner-city, predominantly black children, including any child with a diagnosis of asthma, have found rates of daily antiinflammatory use as low as 12% to 29%,7,27 with Medicaid enrollment independently associated with inadequate therapy.38 Studies of children previously hospitalized for asthma, a group apt to have more severe daily symptoms, report daily antiinflammatory use in the range of 32% to 39%,7,38,39 whereas in a study of moderate to severe asthmatics, based on parents’ self-report of symptoms classified according to the NAEPP 1997 guidelines, only 15% were receiving daily antiinflammatory medication.39 Receiving timely follow-up visits and having seen a specialist also have been found to be significantly associated with lower rates of medication underuse,8 suggesting that future research might examine the interdependence of these aspects of care.
Limitations
There are several limitations to this study that should be mentioned. Claims-level data lack more proximate and detailed information needed to assess asthma severity accurately. Although we attempted to adjust for underlying asthma severity by using proxy measures of asthma medication use and health service utilization, these are gross measures and likely do not capture the full degree of variation in underlying asthma morbidity across study groups.
This analysis does not include variables unavailable in claims-level data that have been identified as significantly associated with asthma medication use or outcomes such as parents knowing how to reach their child’s primary care physician, having telephone access to the family physician, having a written asthma plan, having a peak-flow meter, or having an allergy mattress cover.27,39 Although this study does not include data from Medicaid health maintenance organizations, it is important to note that PCCM plans continue to serve nearly 20% of all Medicaid managed care enrollees nationwide and that, as of 2001, >40% of Medicaid beneficiaries nationwide remained in traditional fee-for-service plans.40 Despite these limitations, the current study offers new information on the differential burden of illness and process of care provided to low-income black, white, and Hispanic children with asthma enrolled in a state Medicaid program.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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As we look forward, there is a need for additional research examining differences in the care received by minority children within Medicaid programs and the extent to which these differences help explain racial/ethnic disparities in asthma outcomes. Claims-level data, which are widely available to state policy makers for all beneficiaries not enrolled in a capitated managed care organization, can provide a useful tool for monitoring key aspects of the process of care and guiding the development of targeted interventions aimed at improving those aspects of care found to most affect risk of future hospitalization. Claims-level data cannot, however, provide insights into the underlying dynamics contributing to racial/ethnic disparities. Additional research is needed to better understand the experience of parents and their children as they interface with the health care system and the changes needed to facilitate access and utilization of effective case management for low-income children with asthma. Such an effort surely will require additional data-collection efforts and resources, but only such a path will accelerate the goal of eliminating racial disparities in health and health care.
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ACKNOWLEDGMENTS |
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We are grateful to Erin Brady, Keira Fuener, and Julie Pelan for assistance in preparing this manuscript; Michael Bronshtein for support in working with the various data sets; and our colleagues at the Massachusetts Division of Medical Assistance and other members of the Expert Clinical Panel for work in developing the measures used in this study.
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FOOTNOTES |
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Reprint requests to (A.E.S.) Georgetown University, Health Policy Institute, 2233 Wisconsin Ave NW, Ste 525, Washington, DC 20007. E-mail: shieldsa{at}georgetown.edu
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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