Outcomes after periodic use of inhaled corticosteroids in children.

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 children's 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 Children's 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.

Asthma self-assessment in a Medicaid population.

BACKGROUND: Self-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. METHODS: We 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 $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. RESULTS: During 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). CONCLUSION: Mailing 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.

C-MOPP: the forgotten regimen plus Rituximab for untreated and relapsed follicular lymphoma.

C-MOPP is a chemotherapy regimen for the treatment of Non-Hodgkin lymphoma (NHL). Because rituximab improves results in B-cell NHL, we added rituximab to C-MOPP, giving it the term C-MOPP-R. We retrospectively report the results of C-MOPP-R treatment for follicular lymphoma at Saint Louis University Cancer Center from 2000-2009. Treatment response was assessed with fusion PET/CT using International Harmonization Project Criteria and toxicity using National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0. Thirty-seven patients with follicular lymphoma were treated at our institution with C-MOPP-R. The complete response rate was ninety-four percent and sixty-eight percent in untreated and relapsed patients, respectively. The median progression-free and overall survivals were not reached with median observation time of 34 months. Development of peripheral neuropathy required truncation of planned vincristine dosing in nearly half of patients. We believe that C-MOPP-R results in excellent response rates, progression-free, and overall survival for untreated and relapsed follicular lymphoma and capped vincristine dosing is essential to optimize safety.

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 children's 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 child's 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.

The immunization delivery effectiveness assessment score: a better immunization measure?

BACKGROUND: Childhood immunization measures, such as the Health Employer Data Information Set (HEDIS) or the National Immunization Survey, assess the percentage of children up-to-date for a specified series of vaccinations. In particular, the HEDIS assesses immunization delivery to children enrolled in managed care organizations (MCO). Such measures do not assess the timeliness of immunization delivery with reference to recommended age standards. To achieve maximal protection against vaccine-preventable diseases, children should receive all immunizations within recommended age intervals-fully "on-time." OBJECTIVE: The Immunization Delivery Effectiveness Assessment (IDEA) is a novel immunization measure that assesses, on a continuous scale, the timeliness of administration of each vaccination with reference to recommended age intervals. Specifically we ask: 1) Do absolute immunization rates differ between HEDIS and IDEA? 2) Does relative MCO performance differ when assessed by the 2 performance measures? 3) How well do MCOs perform relative to the standard of fully on-time immunization? The health services implications of using the timeliness standard to assess childhood immunization delivery is discussed. METHODS: A vaccine-dose IDEA score was developed for each of the 14 vaccination events in the 4:3:1:3:3 combination series (4 diphtheria-pertussis-tetanus:3 polio:1 measles-mumps-rubella:3 Haemophilus influenzae type B:3 hepatitis B). Assessing the actual age of administration with reference to the recommended age of administration generates the vaccine-dose IDEA score. A child's composite IDEA score is obtained by averaging the 14 vaccine-dose IDEA scores. These composite IDEA scores, when averaged among children sampled within the MCO, constitute the MCO's immunization score. SETTING: Retrospective analysis of childhood immunization datasets from a convenience sample of 6 MCOs in 5 states. RESULTS: HEDIS rates ranged from 57% to 75%. IDEA scores ranged from 80% to 90%. Relative rankings of MCO immunization performance were different using HEDIS rates and IDEA scores, respectively. At most, 16% of children in any of these MCOs received all of their immunizations fully on-time. From 47% to 77% of children experienced at least 3 delayed immunizations. CONCLUSIONS: An immunization measure based on timeliness of administration yields both absolute and relative differences in MCO childhood immunization performance when compared with HEDIS rates. By assessing delivery of each component vaccination, the IDEA score permits more detailed analysis of immunization patterns within an MCO and focuses improvement efforts.

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.