Socioeconomic status, drug insurance benefits, and new prescriptions for inhaled corticosteroids in schoolchildren with asthma.

BACKGROUND: Low-income children with asthma are less likely to receive inhaled corticosteroid prescriptions that can prevent asthma morbidity. OBJECTIVE: To determine whether the receipt of inhaled corticosteroids in children with asthma is related to household socioeconomic status and type of drug insurance. DESIGN: Using population-based prescription and health care data from Manitoba, a cohort study of the determinants of receiving new prescriptions for inhaled corticosteroids was conducted in children treated with asthma drugs. PARTICIPANTS: School-aged children (n = 12 481) receiving asthma prescriptions from January 1995 to March 1996 but no inhaled corticosteroid prescriptions in the initial 6-month period. MAIN OUTCOME MEASURES: Household socioeconomic and drug insurance predictors of the probability of receiving a new inhaled corticosteroid prescription from July 1995 to March 1998, following adjustment for disease and health care utilization factors. RESULTS: In comparison with higher-income children insured through a provincial cost-sharing drug plan, the adjusted likelihood ratio for a new inhaled corticosteroid prescription was 0.88 (95% confidence interval, 0.80-0.97) in low-income children insured through the same drug plan and 0.82 (95% confidence interval, 0.76-0.88) in children receiving prescriptions at no charge through provincial income assistance or First Nations benefits programs (Winnipeg, Manitoba). CONCLUSION: Independent of asthma severity, type of drug insurance, or health care utilization patterns, low-income children with asthma are significantly less likely to receive inhaled corticosteroid prescriptions.

Income-based drug benefit policy: impact on receipt of inhaled corticosteroid prescriptions by Manitoba children with asthma.

BACKGROUND: Drug benefit policies are an important determinant of a population's use of prescription drugs. This study was undertaken to determine whether a change in a provincial drug benefit policy, from a fixed deductible and copayment system to an income-based deductible system, resulted in changes in receipt of prescriptions for inhaled corticosteroids by Manitoba children with asthma. METHODS: Using Manitoba's health care administrative databases, we identified a population-based cohort of 10,703 school-aged children who met our case definition for asthma treatment before and after the province's drug benefit policy was changed in April 1996. The effects of the program change on the probability of receiving a prescription for an inhaled corticosteroid and on the mean number of inhaled corticosteroid doses dispensed were compared between a group of children insured under other drug programs (the comparison group) and 2 groups of children insured under the deductible program: those living in low-income neighbourhoods and those living in higher-income neighbourhoods. All analyses were adjusted for a measure of asthma severity. RESULTS: For higher-income children with severe asthma who were covered by the deductible program, the probability of receiving an inhaled corticosteroid prescription and the mean annual number of inhaled corticosteroid doses declined after the change to the drug policy. A trend toward a decrease in receipt of prescriptions was also observed for low-income children, but receipt of prescriptions was unaltered in the comparison group. Before the policy change, among children with severe asthma, the mean annual number of inhaled corticosteroid doses was lowest for low-income children, and this pattern persisted after the change. Among children with mild to moderate asthma, those covered by the deductible program (both low income and higher income) were less likely to receive prescriptions for inhaled corticosteroids than those in the comparison group, and this difference was statistically significant for the higher-income children. INTERPRETATION: The change to an income-based drug benefit policy was associated with a decrease in the use of inhaled corticosteroids by higher-income children with severe asthma and did not improve use of these drugs by low-income children.

The population's use of pharmaceuticals.

OBJECTIVES: In this study, population-based analysis is used to study the extent to which characteristics such as age, sex, socioeconomic status, and region of residence are associated with different patterns of pharmaceutical use. It also includes an examination of whether pharmaceutical use is responsive to differential health needs across the population. RESEARCH DESIGN: Indicators of access, intensity of use, and total expenditures are used to describe Manitobans' use of pharmaceutical agents, consistent with the POPULIS framework. MEASURES: Several rate-based measures have been developed for this purpose: the number of residents who are pharmaceutical users; the number of prescriptions dispensed; the number of different drugs dispensed; the total number of defined daily doses (DDDs) dispensed; and expenditures for pharmaceuticals. The DDD measurement provides a cumulative assessment of total drug use (i.e., across multiple drug categories) and is a useful indicator of a population's total drug exposure. RESULTS: Patterns of use of pharmaceuticals follow patterns similar to those patterns in earlier POPULIS studies on health care access, intensity, and expenditures. In areas where health is generally poorer, a greater number of prescriptions are dispensed. The highest use of pharmaceuticals also was found in the lower-income quintiles and among those at greatest socioeconomic risk, traditionally those with the poorest health status. CONCLUSIONS: This kind of population-based pharmaceutical information can help monitor the effectiveness of policy initiatives, as well as serve to better manage pharmaceutical use within the health care system.

Emergency department use as a component of total ambulatory care: a population perspective.

OBJECTIVES: (a) To describe the overall proportion of ambulatory care provided in emergency departments for a complete urban population, (b) to describe the variation across small geographic areas in the overall proportion of ambulatory care provided in emergency departments and (c) to identify attributes of small-area populations that are related to the provision of high proportions of total ambulatory care in emergency departments. DESIGN: Cross-sectional ecologic study combining 4 sources of secondary data on health service utilization and socioeconomic status. SETTING: Winnipeg. PARTICIPANTS: A total of 657,871 residents of metropolitan Winnipeg in the period April 1991 to March 1992, grouped into 112 neighbourhoods. MAIN OUTCOME MEASURE: A proportion calculated, for each neighbourhood population, from the estimated count of emergency department visits divided by the population's use of total ambulatory care for a sample of 55 days in the study period. RESULTS: The overall proportion of ambulatory care provided in emergency departments was 4.9% (range 2.6% to 10.8%), representing 35.5 emergency department visits per 100 person-years. Neighbourhoods with a higher proportion of total ambulatory care provided in emergency departments were characterized by lower mean household income, a higher proportion of emergency department visits for mental illness and a higher proportion of residents with treaty Indian status. Measures of need for medical care for were not consistently associated with the proportion of ambulatory care received in emergency departments. CONCLUSIONS: In a health care system with an adequate supply of primary care physicians and universal insurance, this study has documented significant variation across small geographic areas in the proportion of total ambulatory care received in emergency departments. In the absence of strong evidence that this variation was associated with underlying need, the results suggest that attention be paid to the accessibility of conventional primary care.