Examining household asthma management behavior through a microeconomic framework

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.

Medication Nonadherence: The Role of Cost, Community, and Individual Factors

OBJECTIVE

To explain the association of out-of-pocket (OOP) cost, community-level factors, and individual characteristics on statin therapy nonadherence.

DATA SOURCES

BlueCross BlueShield of Texas claims data for the period of 2008-2011.

STUDY DESIGN

A retrospective cohort of 49,176 insured patients, aged 18-64 years, with at least one statin refill during 2008-2011 was analyzed. Using a weighted proportion of days covered ratio, differences between adherent and nonadherent groups are assessed using chi-squared tests, t-tests, and a clustered generalized linear model with logit link function.

PRINCIPAL FINDINGS

Statin therapy adherence, measured at 48 percent, is associated with neighborhood-level socioeconomic factors, including race/ethnicity, educational attainment, and poverty level. Individual characteristics influencing adherence include OOP medication cost, gender, age, comorbid conditions, and total health care utilization.

CONCLUSIONS

This study signifies the importance of OOP costs as a determinant of adherence to medications, but more interestingly, the results suggest that other socioeconomic factors, as measured by neighborhood-level variables, have a greater association on the likelihood of adherence. The results may be of interest to policy makers, benefit designers, self-insured employers, and provider organizations.

What patients really think about asthma guidelines: barriers to guideline implementation from the patients' perspective

BACKGROUND

Treatment of asthma does not always comply with asthma guidelines (AG). This may be rooted in direct or indirect resistance on the doctors' and/or patients' side or be caused by the healthcare system. To assess whether patients' concepts and attitudes are really an implementation barrier for AG, we analysed the patients' perspective of a "good asthma therapy" and contrasted their wishes with current recommendations.

METHODS

Using a qualitative exploratory design, topic centred focus group (FG) discussions were performed until theoretical saturation was reached. Inclusion criteria were an asthma diagnosis and age above 18. FG sessions were recorded audio-visually and analysed via a mapping technique and content analysis performed according to Mayring (supported by MAXQDA®). Participants' speech times and the proportion of time devoted to different themes were calculated using the Videograph System® and related to the content analysis.

RESULTS

Thirteen men and 24 women aged between 20 and 77 from rural and urban areas attended five FG. Some patients had been recently diagnosed with asthma, others years previously or in childhood. The following topics were addressed: (a) concern about or rejection of therapy components, particularly corticosteroids, which sometimes resulted in autonomous uncommunicated medication changes, (b) lack of time or money for optimal treatment, (c) insufficient involvement in therapy choices and (d) a desire for greater empowerment, (e) suboptimal communication between healthcare professionals and (f) difficulties with recommendations conflicting with daily life. Primarily, (g) participants wanted more time with doctors to discuss difficulties and (h) all aspects of living with an impairing condition.

CONCLUSIONS

We identified some important patient driven barriers to implementing AG recommendations. In order to advance AG implementation and improve asthma treatment, the patients' perspective needs to be considered before drafting new versions of AG. These issues should be addressed at the planning stage.

TRIAL REGISTRATION

DRKS00000562 (German Clinical Trials Registry).