Using Medicaid claims to identify children with asthma

Influenza Vaccinations Among Privately and Publicly Insured Children With Asthma

OBJECTIVE

Annual influenza vaccination rates for children remain well below the Healthy People 2030 target of 70%. We aimed to compare influenza vaccination rates for children with asthma by insurance type and to identify associated factors.

METHODS

This cross-sectional study examined influenza vaccination rates for children with asthma by insurance type, age, year, and disease status using the Massachusetts All Payer Claims Database (2014-2018). We used multivariable logistic regression to estimate the probability of vaccination accounting for child and insurance characteristics.

RESULTS

The sample included 317,596 child-year observations for children with asthma in 2015-18. Fewer than half of children with asthma received influenza vaccinations; 51.3% among privately insured and 45.1% among Medicaid insured. Risk modeling reduced, but did not eliminate, this gap; privately insured children were 3.7 percentage points (pp) more likely to receive an influenza vaccination than Medicaid-insured children (95% confidence interval [CI]: 2.9-4.5pp). Risk modeling also found persistent asthma was associated with more vaccinations (6.7pp higher; 95% CI: 6.2-7.2pp), as was younger age. The regression-adjusted probability of influenza vaccination in a non-office setting was 3.2pp higher in 2018 than 2015 (95% CI: 2.2-4.2pp), and significantly lower for children with Medicaid.

CONCLUSIONS

Despite clear recommendations for annual influenza vaccinations for children with asthma, low rates persist, particularly for children with Medicaid. Offering vaccines in non-office settings such as retail pharmacies may reduce barriers, but we did not observe increased vaccination rates in the first years after this policy change.

Impact of a pharmaceutical care incentive program on the asthma medication ratio among pediatric patients with persistent asthma enrolled in a Medicaid program

BACKGROUND: Asthma is one of the leading chronic disease states in pediatric patients in Texas. Pharmacy-led interventions such as targeted asthma education, scheduled consultations, and monitoring have shown success in improving asthma outcomes. However, no studies have evaluated the impact of the pharmaceutical care incentive (PCI) programs on Texas Medicaid pediatric beneficiaries. OBJECTIVES: To (1) describe the prevalence of asthma medication utilization and persistent asthma among Medicaid pediatric patients in Texas Health Service Region 11 (HSR 11) and (2) describe the prevalence and impact of PCI program interventions offered by pharmacists to Medicaid pediatric patients or their caregivers at the point-of-service in their medication utilization and asthma medication ratio (AMR). METHODS: This study used a 2-year longitudinal assessment of Medicaid pharmacy claims for beneficiaries aged between 0 and 18 years, with continuous enrollment, and at least 1 asthma medication claim during 2018 and 2019. The prevalence of asthma medication utilization during the study period was described. Also, the prevalence of PCI interventions among beneficiaries with at least 1 asthma medication was described. The prevalence of PCI interventions was also estimated for beneficiaries with persistent asthma. The AMR for beneficiaries with persistent asthma was calculated and compared for those with and without at least 1 PCI intervention. RESULTS: 22,051 beneficiaries with continuous enrollment between the ages of 0 and 18 years and with at least 1 pharmacy claim for an asthma medication during the study period were included. The overall prevalence of asthma medication utilization was 14.55%. 374 (1.70%) beneficiaries with at least 1 asthma medication received at least 1 asthma PCI intervention. Among beneficiaries that received at least 1 asthma PCI intervention, 158 (42.25%) were on rescue medication only; 4 (1.07%) were on maintenance medication only; and 212 (56.68%) were on rescue and maintenance medications. The overall prevalence of persistent asthma was 4.86%. 52 (0.76%) persistent asthma cases received at least 1 asthma PCI intervention after the index date. The overall unadjusted mean AMR (SD) for the 6,885 beneficiaries with persistent asthma was 0.50 (0.19). The adjusted AMR (SD) among beneficiaries with persistent asthma was reported at 0.530 (0.026) for beneficiaries who received at least 1 PCI intervention and 0.483 (0.002) for beneficiaries who did not receive a PCI intervention (P = 0.066). Beneficiaries with persistent asthma generated 64.35% of the total asthma pharmacy claims during 2019. CONCLUSIONS: Despite a high utilization of asthma medications among Medicaid pediatric beneficiaries, pharmacists servicing this group are underusing the PCI program interventions. An increase in the AMR among patients with persistent asthma receiving PCI interventions was observed when compared with those without PCI interventions. However, the difference was not statistically significant. Subsequent studies should include larger groups of beneficiaries receiving PCI interventions to establish the effect of PCI interventions on AMR before widespread implementation. DISCLOSURES: This research project was supported by the Global Institute for Hispanic Health (GIHH) through research grant M1803961. The authors have nothing to disclose. A part of this study was presented as a poster at the AMCP 2020 Virtual Annual Meeting and Exposition Meeting, April 21-24, 2020.

The validity of diagnostic algorithms to identify asthma patients in healthcare administrative databases: a systematic literature review

OBJECTIVES

To review the available evidence supporting the validity of algorithms to identify asthma patients in healthcare administrative databases.

METHODS

A systematic literature search was conducted on multiple databases from inception to March 2020 to identify studies that reported the validity of case-finding asthma algorithms applied to healthcare administrative data. Following an initial screening of abstracts, two investigators independently assessed the full text of studies which met the pre-determined eligibility criteria. Data on study population and algorithm characteristics were extracted. A revised version of the Quality Assessment of Diagnostic Accuracy Studies tool was used to evaluate the risk of bias and generalizability of studies.

RESULTS

A total of 20 studies met the eligibility criteria. Algorithms which incorporated ≥1 diagnostic code for asthma over a 1-year period appeared to be valid in both adult and pediatric populations (sensitivity ≥ 85%; specificity ≥ 89%; PPV ≥ 70%). The validity was enhanced when: (1) the time frame to capture asthma cases was increased to two years; (2) ≥2 asthma diagnostic codes were considered; and (3) when diagnoses were recorded by a pulmonologist. Algorithms which integrated pharmacy claims data appeared to correctly identify asthma patients; however, the extent to which asthma medications can improve the validity remains unclear. The quality of several studies was high, although disease progression bias and biases related to self-reported data was observed in some studies.

CONCLUSIONS

Healthcare administrative databases are adequate sources to identify asthma patients. More restrictive definitions based on both asthma diagnoses and asthma medications may enhance validity, although further research is required to confirm this hypothesis.

Performance of ICD-10-CM diagnosis codes for identifying children with Sickle Cell Anemia

OBJECTIVE

To develop, test, and validate the performance of ICD-10-CM claims-based case definitions for identifying children with sickle cell anemia (SCA).

DATA SOURCES

Medicaid administrative claims (2016) for children <18 years with potential SCA (any D57x diagnosis code) and newborn screening records from Michigan and New York State.

STUDY DESIGN

This study is a secondary data analysis.

DATA COLLECTION/EXTRACTION METHODS

Using specific SCA-related (D5700, D5701, and D5702) and nonspecific (D571) diagnosis codes, 23 SCA case definitions were applied to Michigan Medicaid claims (2016) to identify children with SCA. Measures of performance (sensitivity, specificity, area under the ROC curve) were calculated using newborn screening results as the gold standard. A parallel analysis was conducted using New York State Medicaid claims and newborn screening data.

PRINCIPAL FINDINGS

In Michigan Medicaid, 1597 children had ≥1 D57x claim; 280 (18 percent) were diagnosed with SCA. Measures of performance varied, with sensitivities from 0.02 to 0.97 and specificities from 0.88 to 1.0. The case definition of ≥1 outpatient visit with a SCA-related or D571 code had the highest area under the ROC curve, with a sensitivity of 95 percent and specificity of 92 percent. The same definition also had the highest performance in New York Medicaid (n = 2454), with a sensitivity of 94 percent and specificity of 86 percent.

CONCLUSIONS

Children with SCA can be accurately identified in administrative claims using this straightforward case definition. This methodology can be used to monitor trends and use of health services after transition to ICD-10-CM.

Sex differences in the association between asthma incidence and modifiable risk factors in Korean middle-aged and older adults: NHIS-HEALS 10-year cohort

Background

This study investigated the sex-specific incidence of asthma and the effects of modifiable risk factors, particularly obesity, on asthma incidence among middle-aged and older individuals in Korea.

Methods

We used data from the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS), which includes health examinees aged 40–79 years in 2002–2003. In total, 459,529 participants with baseline anthropometric measurements were followed-up for 10 years and the development of asthma was evaluated (2004–2013). For subgroup analysis, 246,019 participants who had body mass index (BMI) and waist circumference (WC) measurements taken in 2008–2009 were included in the analysis of the asthma incidence for 2010–2013. Factors associated with asthma were analysed using Cox proportional hazard models.

Results

The cohort comprised 4,248,813 (men, 2,358,541; women, 1,890,272) person-years of follow-up for 2004–2013. The asthma incidence was 10.58 and 15.03 per 1000 person-years for men and women, respectively. Asthma incidence increased with age, notably so in men. Obesity based on the baseline BMI was significantly associated with asthma development in both sexes (men, HR = 1.23, 95% confidence interval (CI) = 1.13–1.34; women, HR = 1.40 95% CI = 1.32–1.48). High WC was also related to asthma incidence in both sexes with statistical significance (men, HR = 1.34, 95% CI = 1.16–1.57; women, HR = 1.19 95% CI = 1.03–1.37). Analysis of the combined effects of BMI and WC showed that men had a higher asthma risk in the group with both general obesity and abdominal obesity than in the group with non-abdominal obesity and normal BMI. However, obese women had a higher risk of asthma regardless of abdominal obesity. Similarly, smoking was associated with asthma in both sexes but drinking and physical activity showed different associations between the sexes.

Conclusions

Our results revealed that asthma incidence was substantially high at old age and lifestyle factors were associated with asthma development. Practical strategies including weight control and healthy lifestyle modification are required to prevent asthma in older people.

Identifying perianal fistula complications in pediatric patients with Crohn's disease using administrative claims

Background

Although perianal fistulas occur commonly in pediatric Crohn’s disease (CD), evaluations of health services have been limited since no validated claims-based methods exist for identifying cases.

Objective

To develop and validate accurate case definitions for perianal fistulas among pediatric patients with CD from administrative claims.

Methods

Retrospective cohort study in which we developed and tested candidate case definitions for perianal fistula. Patients (age 5–21 years between 2005–2012) with CD enrolled in Michigan Medicaid with healthcare at University of Michigan were identified via claims. Medical records were obtained from all identified patients, whose entire records were abstracted. Medical record evidence for perianal fistula was considered the “gold standard” against which candidate case definitions were compared. The reference case definition of perianal fistula (ICD9 565.1) and candidate case definitions were evaluated.

Results

Of 843 patients identified via claims, 274 (33%) met CD criteria for inclusion. The true perianal fistula rate among CD patients was 18% (n = 49). The top-performing candidate case definition identified 15% (n = 42), had sensitivity of 77.6%, specificity of 98.2%, positive predictive value (PPV) 90.5%, negative predictive value (NPV) 95.3%, and area under receiver operator characteristic curve (ROC) of 0.88. In contrast, the reference case definition identified 9% (n = 26), sensitivity 51.0%, specificity 99.6%, PPV 96.2%, NPV 90.3%, and had an area under ROC of 0.75.

Conclusions

We demonstrated that it is feasible to use administrative claims data to accurately identify pediatric patients with perianal fistula complications. Claims-based case definitions were found to be highly accurate through medical record review, providing a high degree of confidence for future studies where chart review is not feasible. These claims-based methods can be applied to claims data in other settings for the evaluation of health services utilization as well as to assess the comparative effectiveness of prevention and treatment strategies.

Optimizing community-level surveillance data for pediatric asthma management

Community-level approaches for pediatric asthma management rely on locally collected information derived primarily from two sources: claims records and school-based surveys. We combined claims and school-based surveillance data, and examined the asthma-related risk patterns among adolescent students. Symptom data collected from school-based asthma surveys conducted in Oakland, CA were used for case identification and determination of severity levels for students (high and low). Survey data were matched to Medicaid claims data for all asthma-related health care encounters for the year prior to the survey. We then employed recursive partitioning to develop classification trees that identified patterns of demographics and healthcare utilization associated with severity. A total of 561 students had complete matched data; 86.1% were classified as high-severity, and 13.9% as low-severity asthma. The classification tree consisted of eight subsets: three indicating high severity and five indicating low severity. The risk subsets highlighted varying combinations of non-specific demographic and socioeconomic predictors of asthma prevalence, morbidity and severity. For example, the subset with the highest class-prior probability (92.1%) predicted high-severity asthma and consisted of students without prescribed rescue medication, but with at least one in-clinic nebulizer treatment. The predictive accuracy of the tree-based model was approximately 66.7%, with an estimated 91.1% of high-severity cases and 42.3% of low-severity cases correctly predicted. Our analysis draws on the strengths of two complementary datasets to provide community-level information on children with asthma, and demonstrates the utility of recursive partitioning methods to explore a combination of features that convey asthma severity.

Use of Medicaid and housing data may help target areas of high asthma prevalence

OBJECTIVE

To determine if there was a significant difference between mold contamination and asthma prevalence in Detroit and non-Detroit Michigan homes, between newer and older homes, and if there is a correlation between mold contamination and measures of Medicaid use for asthma in the 25 Detroit zip codes.

METHODS

Settled dust was collected from homes (n = 113) of Detroit asthmatic children and from a representative group of Michigan homes (n = 43). The mold contamination for each home was measured using the Environmental Relative Moldiness Index (ERMI) scale and the mean ERMI values in Detroit and non-Detroit homes were statistically compared. Michigan Medicaid data (13 measures related to asthma) in each of the 25 zip codes in Detroit were tested for correlation to ERMI values for homes in those zip codes.

RESULTS

The mean ERMI value (14.5 ± 8.0) for Detroit asthmatic childrens' homes was significantly (Student's t-test, p < 0.001) greater than the mean ERMI value (2.1 ± 6.2) for the non-Detroit homes. Detroit homes > 60 years old had significantly (p = 0.01) greater mean ERMI values than Detroit homes ≤ 60 years old (15.87 vs. 11.25). The percentage of children that underwent spirometry testing for their persistent asthma (based on Medicaid data) was significantly, positively correlated with the mean ERMI values of the homes in the 25 zip codes.

CONCLUSIONS

Applying Medicaid-use data for spirometry testing and locating a city's older housing stock might help find foci of homes with high ERMI values.

Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study

Background

Patient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established.

Objective

We evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success.

Methods

We conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework.

Results

We invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success.

Conclusions

Although use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children.

ClinicalTrial

Clinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3)

Lead Testing in a Pediatric Population: Underscreening and Problematic Repeated Tests

CONTEXT

Underscreening and problematic repeat lead testing in children.

OBJECTIVE

Identify proportion of underscreening for elevated blood-lead levels in children. For children who receive a lead test, measure the level of problematic repeat lead tests, defined as those with a high probability of not meeting recommended guidelines for lead testing in children measured using a combination of patients' age, test type and sequencing, days between tests, and encounter diagnosis coding.

DESIGN

A population-based retrospective cross-sectional design.

SETTING

All health care services organizations in the state of Minnesota that delivered health services to the defined study population.

PARTICIPANTS

The study population was a Medicaid cohort of 12 436 children aged 0 to 18 years observed over a 1-year period.

MAIN OUTCOME MEASURES

Proportion of eligible children not receiving at least 1 lead test; proportion of problematic repeat lead tests.

RESULTS

Thirty-five percent of children who should have received at least 1 lead test (n = 1714) during the study period did not. A total of 1856 children had at least 1 lead test and 190 had 2 or more. Fifty percent (50%) of the repeat tests were identified as problematic, representing 5.1% of the lead tests performed. Repeat tests performed in different health systems than the systems where the initial tests were performed had 5.3 times greater odds (adjusted odds ratio: 5.3 [95% confidence interval, 2.8-9.9]) of being problematic.

CONCLUSIONS

The current approach to delivering mandatory lead testing across the state Medicaid population does not ensure that children are appropriately tested and has potential inefficiencies in that testing when it does take place. Use of multiple health care systems is associated with increased potential inefficiencies. Future Medicaid accountable care agreements between the state Medicaid program and participating health systems should emphasize clear population accountability for test screenings to improve patients' safety. A central queryable health resource or health information exchange may enable this.

Do Pediatric Patients Who Receive Care Across Multiple Health Systems Have Higher Levels of Repeat Testing?

Repetition by clinicians of the same tests for a given patient is common. However, not all repeat tests are necessary for optimal care and can result in unnecessary hardship. Limited evidence suggests that an electronic health record may reduce redundant laboratory testing and imaging by making previous results accessible to physicians. The purpose of this study is to establish a baseline by characterizing repeat testing in a pediatric population and to identify significant risk factors associated with repeated tests, including the impact of using multiple health systems. A population-based retrospective cross-sectional design was used to examine initial and repeat test instances, defined as a second test following an initial test of the same type for the same patient. The study population consisted of 8760 children with 1-25 test claims over a 1-year period. The study setting included all health care service organizations in Minnesota that generated these claims. In all, 17.2% of tests met the definition of repeat test instances, with several risk factors associated with per patient repeat test levels. The incidence of repeat test instances per patient was significantly higher when patients received care from more than 1 health system (adjusted incidence rate ratio 1.4; 95% confidence interval: 1.3-1.5). Repeat test levels are significant in pediatric populations and potentially actionable. Interoperable health information technology may reduce the incidence of repeat test instances in pediatric populations by making prior test results readily accessible. (Population Health Management 2016;19:102-108).

A cross-sectional study of the identification of prevalent asthma and chronic obstructive pulmonary disease among initiators of long-acting β-agonists in health insurance claims data

BACKGROUND

Claims data are potentially useful for identifying long-acting β-agonist (LABA) use by patients with asthma, a practice that is associated with increased mortality. We evaluated the accuracy of claims data for classifying prevalent asthma and chronic obstructive pulmonary disease (COPD) among initiators of LABAs.

METHODS

This study included adult LABA initiators during 2005-2008 in a US commercial health plan. Diagnosis codes from the 6 months before LABA initiation identified potential asthma or COPD and a physician adjudicated case status using abstracted medical records. We estimated the positive predictive value (PPV) and 95% confidence intervals (CI) of covariate patterns for identifying asthma and COPD.

RESULTS

We sought 520 medical records at random from 225,079 LABA initiators and received 370 (71%). The PPV for at least one asthma claim was 74% (CI 63-82), and decreased as age increased. Having at least one COPD claim resulted in a PPV of 82% (CI 72-89), and of over 90% among older patients, men, and recipients of inhaled anticholinergic drugs. Only 2% (CI 0.2-7.6) of patients with a claim for COPD alone were found to have both COPD and asthma, while 9% (CI 4-16) had asthma only. Twenty-one percent (CI 14-30) of patients with claims for both diagnoses had both conditions. Among patients with no asthma or COPD claims, 62% (CI 50-72) had no confirmed diagnosis and 29% (CI 19-39) had confirmed asthma.

CONCLUSIONS

Subsets of patients with asthma, COPD, and both conditions can be identified and differentiated using claims data, although categorization of the remaining patients is infeasible. Safety surveillance for off-label use of LABAs must account for this limitation.

A data mining approach for grouping and analyzing trajectories of care using claim data: the example of breast cancer

Background

With the increasing burden of chronic diseases, analyzing and understanding trajectories of care is essential for efficient planning and fair allocation of resources. We propose an approach based on mining claim data to support the exploration of trajectories of care.

Methods

A clustering of trajectories of care for breast cancer was performed with Formal Concept Analysis. We exported Data from the French national casemix system, covering all inpatient admissions in the country. Patients admitted for breast cancer surgery in 2009 were selected and their trajectory of care was recomposed with all hospitalizations occuring within one year after surgery. The main diagnoses of hospitalizations were used to produce morbidity profiles. Cumulative hospital costs were computed for each profile.

Results

57,552 patients were automatically grouped into 19 classes. The resulting profiles were clinically meaningful and economically relevant. The mean cost per trajectory was 9,600€. Severe conditions were generally associated with higher costs. The lowest costs (6,957€) were observed for patients with in situ carcinoma of the breast, the highest for patients hospitalized for palliative care (26,139€).

Conclusions

Formal Concept Analysis can be applied on claim data to produce an automatic classification of care trajectories. This flexible approach takes advantages of routinely collected data and can be used to setup cost-of-illness studies.

Statewide pandemic influenza vaccination reminders for children with chronic conditions

OBJECTIVES

We evaluated the use of a statewide immunization information system (IIS) to target influenza vaccine reminders to high-risk children during a pandemic.

METHODS

We used Michigan's IIS to identify high-risk children (i.e., those with ≥ 1 chronic condition) aged 6 months to 18 years with no record of pH1N1 vaccination among children currently or previously enrolled in Medicaid (n = 202,133). Reminders were mailed on December 7, 2009. We retrospectively assessed children's eligibility for evaluation and compared influenza vaccination rates across 3 groups on the basis of their high-risk and reminder status.

RESULTS

Of the children sent reminders, 53,516 were ineligible. Of the remaining 148,617 children, vaccination rates were higher among the 142,383 high-risk children receiving reminders than among the 6234 high-risk children with undeliverable reminders and the 142,383 control group children without chronic conditions who were not sent reminders.

CONCLUSIONS

Midseason reminders to parents of unvaccinated high-risk children with current or past Medicaid enrollment were associated with increased pH1N1 and seasonal influenza vaccination rates. Future initiatives should consider strategies to expand targeting of high-risk groups and improve IIS reporting during pandemic events.