Eric M Sarpong and G Edward Miller AHRQ Conference September 20 2011 Introduction Asthma chronic complex and costly health condition Estimated costs of asthma in the US 197 billion ID: 225801
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Slide1
Racial-Ethnic Differences in Childhood Asthma Treatment
Eric M. Sarpong and G. Edward Miller
AHRQ Conference
September 20, 2011Slide2
Introduction
Asthma – chronic, complex and costly health condition
Estimated costs of asthma in the U.S. - $19.7 billion
(NHLBI, 2007)
Why childhood asthma medication use?
Recent significant increases in:
Treated prevalence
Health care and prescribed asthma drug expenditures (
Miller & Sarpong
)
Recent changes in asthma care
Treatment guidelines
(NAEPP-EPR3, 2007)
- Inhaled corticosteroid (ICS); preferred first-line therapy for persistent asthma
Changes in use and availability of new pharmacotherapies
Increased use of controller medications
Decreased use of mono-therapy with relievers
Differences in asthma treatment persistsSlide3
Pharmaceutical Treatment of Asthma
Recommended treatment depends on asthma severity
(
NAEPP-EPR3, 2007
)
Controllers (e.g., i
nhaled corticosteroid)
Used in managing asthma symptoms, by minimizing inflammation and reducing the risk of serious exacerbations
Recommended for all children with persistent asthma
Relievers (e.g.,
inhaled short acting beta agonists)
Used in managing moderate or severe asthma attacks by promptly relaxing airway muscles
Recommended for all children with intermittent asthmaSlide4
Treated Prevalence of Childhood Asthma by Race-Ethnicity, 2005-2008
Source: MEPS, 2005-2008. Estimates for insured children with reported treatment for asthma. Differences from NH Whites significant at p < .05. Slide5
Use of Controllers Among Children With Treatment for Asthma, 2005-2008
Source: MEPS, 2005-2008. Estimates for insured children with reported treatment for asthma. Differences from NH Whites significant at p < .05. Slide6
Use of Relievers Only , Among Children with Treatment for Asthma, 2005-2008
Source: MEPS, 2005-2008. Estimates for insured children with reported treatment for asthma. Differences from NH Whites significant at p < .05. Slide7
Differences in Treated Prevalence and Use of Asthma Medications
NH Black children - more likely than NH White and Hispanic children to be treated for asthma
NH Black and Hispanic children - less likely than NH White children to use controllers
NH Black and Hispanic children - more likely than NH White children to use relievers onlySlide8
Previous Research
Large body of literature with mixed evidence on differences in children
’
s use of asthma medication
Some studies find no differences by race-ethnicity, others do find a difference
Studies differ on a number of dimensions
Time period
Population (e.g., Medicaid, private claims, nationally representative)Degree to which they control for differences in underlying characteristics across groups Slide9
Research Objective and Contribution
Research Objective
Examine differential use of asthma medication by race-ethnicity
Examine extent to which differences in mean predisposing, enabling and need characteristics explain differences in use
New Contribution
Previous literature limited - Medicaid data, administrative data or community samples, key variables unavailable
Comprehensive look at differences using nationally representative data (MEPS)
Provide descriptive information on reasons for differences and possible approaches to addressing these differencesSlide10
Analytic Approach
Describe differences in controllers and relievers only use by race-ethnicity
Estimate pooled regression models with binary outcomes (i.e., controllers and relievers only)
Explanatory variables
Predisposing (e.g., socio-demographics, geographic)
Enabling (e.g., health insurance, family income/structure and parental education/employment status)
Need (e.g., health status, co-occurring conditions)
Use Oaxaca-Blinder method - decompose differences into:Explained - differences due to mean differences in explanatory variablesUnexplained - differences due to differences in estimated coefficientsSlide11
Data
Data
2005-2008 Medical Expenditure Panel Survey (MEPS)
Population studied
Insured children (ages 0-17) with reported treatment for asthma
Treatment = health service use associated with asthma
Sample size
N = 813 NH White childrenN = 608 NH Black childrenN = 644 Hispanic childrenDrugs Link MEPS drug data by NDC to the Multum LexiconUse generic names to categorize drugs as controllers or relieversMeasures: any use of controllers and relievers onlySlide12
Descriptive Results - Differences in Mean Characteristics
NH Black children more likely than NH White children to
Be covered by public insurance, live in an MSA and in the south (
predisposing
)
Live in families with low levels of family income, low parental education, unmarried parent and unemployed parent (
enabling
)Be in fair/poor physical health (need)Hispanic children more likely than NH White children toBe covered by public insurance, live in an MSA, in the west, have non-native parents and parents with risky attitudes towards health (predisposing) Live in families with low levels of family income, low parental education, unmarried parent, unemployed parent and live in a larger family (enabling)Be in fair/poor physical health (need)Slide13
Multivariate Results - Predictors of Controller and Reliever Only Use
Positive effects on controller use
Age 5-11, native parents, married parent, fair/poor physical health, and having treatment for allergies
Negative effects on controller use
Female, MSA, western region, low family income, parental education, and large family
Positive effects on reliever only use
Female, MSA, western region, native parents, low family income, and large family
Negative effects on reliever only useAge 5-11, married parent, fair/poor physical health, and having treatment for allergies
Results are based on coefficient estimates from pooled linear probability models. Slide14
Oaxaca-Blinder Decomposition - NH Whites vs. NH Blacks, Controllers
Important variables
Enabling
Low income
≤ High school
Family of > 4
Unmarried
Source: MEPS, 2005-2008. Estimates for insured children with reported treatment for asthma. Differences from NH Whites, significant at p < .10.
ExplainedSlide15
Oaxaca-Blinder Decomposition Results - NH Whites vs. NH Blacks, Relievers Only
Important variables
Enabling
Low income
Family of > 4
Unmarried
Source: MEPS, 2005-2008. Estimates for insured children with reported treatment for asthma. Differences from NH Whites, significant at p < .10.
ExplainedSlide16
Oaxaca-Blinder Decomposition Results - NH Whites vs. Hispanics, Controllers
Important variables
Predisposing
MSA
West
Non-native parents
Enabling
Low income ≤ High school Family of > 4 Unmarried
Source: MEPS, 2005-2008. Estimates for insured children with reported treatment for asthma. Differences from NH Whites, significant at p < .10.
ExplainedSlide17
Oaxaca-Blinder Decomposition Results - NH Whites vs. Hispanics, Relievers only
Important variables
Enabling
Low income
≤ High school
Family of > 4
Unmarried
Source: MEPS, 2005-2008. Estimates for insured children with reported treatment for asthma. Differences from NH Whites, significant at p < .10.
ExplainedSlide18
Interpretation of Oaxaca-Blinder Decomposition Results
Several characteristics in the domains of the behavioral model were associated with
Controller use
Reliever only use
Our model
Explained most differences in:
Controller use for NH Blacks and Hispanics
Reliever only use for HispanicsDifferences in reliever only use for NH Blacks, largely unexplainedUnobservable factors - differences in responses to characteristics, may be importantSlide19
Limitations and Future Research
Limitations
No measure of asthma severity
Results may change if severity differs across groups
Non-causal descriptive model
Future research
Depart from linear probability models
Use non-parametric approachRaking (Pylypchuk and Selden, 2008, JHE)Follow previous approaches Kirby et al, 2010 MCRR and Hudson et al, 2007Slide20
Conclusions
Non-Hispanic whites: low asthma treated prevalence and reliever only use and, higher controller use
Enabling factors explained some, not all, of the differences in controller and reliever only use for NH Blacks and Hispanics
Predisposing factors explained some of the differences in controller use for Hispanics
Some unobservable characteristics may have also played a role
Results are consistent with studies in other therapeutic classes of drugs and disease areasSlide21
References
Miller G.E. and Sarpong E.M. Trends in the Pharmaceutical Treatment of Children
’
s Asthma, 1997 to 2008. Research Findings No. 31. September 2011. Agency for Healthcare Research and Quality, Rockville, MD.
http://meps.ahrq.gov/mepsweb/data_files/publications/
Kirby JB, Hudson J, Miller GE. (2010). Explaining Racial and Ethnic Differences in Antidepressant Use Among Adolescents Med Care Res Rev, 67: 342-363
Crocker D, Brown C, Moolenaar R, Moorman J, Bailey C, Mannino D, Holguin F. (2009). Racial and ethnic disparities in asthma medication usage and health-care utilization: data from the National Asthma Survey. Chest,136(4):1063-71. Epub 2009 Jun 30.
Pylypchuk, Y. and T. M. Selden. (2008). A discrete choice decomposition analysis of racial and ethnic differences in children’s health insurance coverage. Journal of Health Economics 27: 1109-1128.Chen AY, Escarce JJ. (2008). Family Structure and the Treatment of Childhood Asthma. Medical Care , 46: 174-184Hudson, J. L., Miller, G. E., & Kirby, J. B. (2007). Explaining racial and ethnic differences in children’s use of stimulant medications. Medical Care, 45, 1068-1075.National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma: Full Report 2007. Bethesda, MD: National Institutes of Health, US Dept of Health and Human Services, National Heart, Lung, and Blood Institute; 2007.
Shields A, Comstock C, Weiss KB. (2004). Variations in asthma care by race/ethnicity among children enrolled in a state Medicaid program. Pediatrics,113:496 –504.
Finkelstein JA, Lozano P, Farber HJ, et al. (2002). Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med,56(6):562-7.
Lieu TA, Lozano P, Finkelstein J, et al. (2002). Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics,109:857– 865.
Blinder, A. (1973). Wage discrimination: Reduced form and structural estimates. Journal of Human Resources, 8, 436-455.
Oaxaca, R. L. (1973). Male-female wage differentials in urban labor markets. International Economic Review, 14, 693-709.