Impact of Payor-Initiated Switching of Inhaled Corticosteroids on Lung Function.

OBJECTIVES: To evaluate the impact of a payor-initiated formulary change in inhaled corticosteroid coverage on lung function in patients with asthma and on provider prescribing practices. This formulary change, undertaken in August 2016 by a Medicaid payor in Kentucky, eliminated coverage of beclomethasone dipropionate, a metered dose inhaler (MDI), in favor of mometasone furoate, available as MDI and dry powder inhaler (DPI). STUDY DESIGN: A retrospective chart review was conducted on children with asthma ages 6-18 years covered by the relevant payor from a university-based pediatric practice who were seen before the formulary change (February to July 2016) and after (February to July 2017). Spirometry data from each visit was compared using the paired Student t test. RESULTS: Fifty-eight patients were identified who were initially on beclomethasone dipropionate and had spirometry available at both visits. Those who switched from an MDI to a DPI (n = 24) saw a decline in median predicted forced expiratory volume in 1 second from 98.5% to 91% (P = .013). A decline was also seen in forced expiratory flow at 25%-75%, from 89.5% predicted to 76% predicted (P = .041). No significant changes were observed in children remaining on an MDI. Seven patients discontinued inhaled corticosteroid therapy. CONCLUSIONS: This study suggests insurance formulary changes leading to use of a different inhaler device may have a detrimental impact on pediatric lung function, which may be a surrogate measure for overall asthma control. This could be due to a lack of adequate timely educational intervention as well as the inability of some children to use DPIs.

A simplified table improves the recognition of paediatric hypertension.

AIM: Unrecognised and untreated hypertension can lead to significant morbidity and mortality over time. In a 2003 chart review, we found that our providers only recognised 15% of hypertensive blood pressure (BP). Our objective was to determine whether a simplified BP table improves the recognition of elevated BP in children. METHODS: We developed a simplified BP table for children 3-18 years and posted it in provider work areas beginning August 2006. We reviewed a retrospective sample of well visits for children aged 3-18 years, with equal numbers by sex and year of age, presenting at a university-based paediatric clinic between January and August 2007. Visit notes for all children with elevated BP values ≥ 90th percentile were reviewed to identify whether the provider recognised that the BP was elevated. RESULTS: In 493 well visits, 85 (17.2%) children had pre-hypertensive (90th to < 95th percentile) and 100 (20.3%) had hypertensive (≥ 95th percentile) BP values. Providers recognised elevations in 34 (40%) pre-hypertensive and 77 (77%) hypertensive measurements. Recognition was significantly more common for those in the hypertensive than the pre-hypertensive range (χ² = 24.9, degrees of freedom= 1, P < 0.001). Compared with our 2003 data, recognition of hypertensive BP values was significantly greater (77% vs. 15%) (t = 14.479, degrees of freedom = 98, P <0.001) after introduction of the simplified BP table. CONCLUSIONS: Use of a simplified BP table can lead to significantly improved recognition of elevated BP in children.