Disparities Between Asthma Management and Insurance Type Among Children

o r i g i n a l c o m m u n i c a t i o n Disparities Between Asthma Management and Insurance Type Among Children Crystal N. Piper, MPH, MHA, PhD; Keith Elder, PhD; Saundra Glover, PhD; Jong-Deuk Baek, PhD; Keva Murph, MHA Asthma is a chronic illness among children. Minority children may be vulnerable to asthma complications since more than half are from households that are poor or near poor, and some have no health insurance. Asthma management plans are important for the long-term treatment of asthma and beneficial for self-management. This study analyzed insurance type and the relationship between having an asthma management plan among children across all races with asthma. This study utilized the 2002 and 2003 National Health Interview Survey. Findings showed that whites were significantly more likely than Non-Hispanic blacks and Hispanics to have an asthma management plan (OR, 1.66; p =.0031). In this study, children who reported Children s Health Insurance Program (CHIP) coverage were twice as likely to have an asthma management plan (OR, 2.67; p =.0004). Mandating all insurers to provide an asthma management plan to children with asthma may reduce the race-based inequities and differences in asthma management plan status. Keywords: children/adolescents n asthma n race/ ethnicity n health disparities n insurance J Natl Med Assoc. 2010;102:556-561 Author Affiliations: College of Health and Human Services-Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina (Dr Piper); Department of Health Services Administration, University of Alabama Birmingham, Birmingham, Alabama (Dr Elder); Institute for Partnership to Eliminate Health Disparities, University of South Carolina Arnold School of Public Health, Columbia, South Carolina (Dr Glover and Ms Murph); Graduate School of Public Health, San Diego State University, San Diego, California (Dr Baek). Correspondence: Crystal N. Piper, MPH, MHA, PhD, University of North Carolina at Charlotte, College of Health and Human Services-Department of Public Health Sciences, 9201 University City Blvd, Charlotte, NC 28223 (cpiper1@uncc.edu). In the United States, asthma is a leading chronic illness among young children and adolescents. Approximately 5 million children in the United States suffer from asthma. 1 Asthma creates a burden on racial/ethnic minorities and low-income children. 2 In a study conducted by Quinn et al, non-hispanic blacks were twice as likely to have undiagnosed asthma as non-hispanic whites and Hispanics. 3 Minority children with asthma may be particularly vulnerable or relatively incapable of protecting their own interests, since more than half are from households that are poor or near poor, and 35%, respectively, have no health insurance. 4 Newacheck et al found that even in an environment of public insurance expansion, poor adolescents face disadvantages in health services experiences. 5 Toward that end, poor children were more likely than middle- to high-income children to lack private insurance or have public insurance such as Medicaid. 6 Medicaid-eligible children are more likely to be minority and vulnerable, and to suffer poor outcomes from asthma. 7 Thus, minority and low-income children are more likely to receive health care services through Medicaid programs,and the data are not encouraging for this population. 7 According to Bratton et al, Medicaidinsured children with asthma are less likely to receive health care services within the recommended national guidelines. 8 In that study, the primary care providers of Medicaid-eligible children reported the communication between low-income families to be more difficult than higher-income families. This study also found that seminars enhancing the primary care provider s knowledge of teaching techniques for asthma care were significant, but these practices would require frequent reinforcement. The National Institutes of Health, National Heart, Lung, and Blood Institute (NHLBI) created recommendations to encourage physicians to provide guidelines to improve the home management of asthma exacerbations to all asthma patients, which included having a written asthma action plan with information on what to do at home, when to call the clinician, and when to seek emergency care. 9 An asthma management plan is a document tailored specifically for the child in which the health care provider, along with the child and family, develop an action plan to assist in managing asthma episodes. 9 The plan provides the individual with asthma and the family procedures on how to use preventive medications, emergency medications, the peak flow meter, and when to seek health care and emergency care. 9 Asthma management plans are an essential component for the long-term treatment of pediatric asthma and beneficial for self-management. 10,11 Having an asthma management plan is also associated with fewer asthmatic episodes. 12 Fredrickson et al found that most asthmatic patients belong to vulnerable groups that have 556 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 7, JULY 2010

greater barriers to effective asthma management, and black children in a managed Medicaid population had worse asthma status and were less likely than white children to engage in preventive asthma practices. 7,13 Prior studies have not identified a consistent relationship between insurance status and having an asthma management plan. In a survey conducted by Bratton et al, primary care providers with patients insured by Medicaid reported less asthma self-management guideline recommendations and use of written asthma management plans. 8 The gap in the findings of the study by Bratton et al, which leads to the necessity of continuous examination, is the lack of analysis of other insurance options and the need for continuous reinforcement in asthma management practices. 8 This study will make a new contribution by identifying a clear relationship between insurance types and having an asthma management plan, and identifying the factors and characteristics that lead to asthma management practices. The aim of this study is to examine insurance type and the relationship between having an asthma management plan among children with asthma across all races in the United States. METHODS Theoretical Framework Having access to appropriate health care services is often a challenge for vulnerable populations such as lowincome minority children. Children who do not receive adequate healthcare services usually use inappropriate services and suffer from more serious medical problems. 14 The Aday and Andersen Behavioral Model (Figure) is a framework for understanding access to care. 16 In this study, the Aday and Andersen framework was used to identify predictors and determinants of access to appropriate health care services, specifically insurance type and physician recommendations of an asthma management plan. The Aday and Andersen model suggests that an individual s use of health services simply does not include structural changes and service utilization, but it is a function of predisposing factors (ie, race, age, gender), enabling factors (ie, income level, education level, insurance coverage), and need factors (asthma/asthma-related symptoms/asthma management) to determine how a patient accesses and utilizes health care services. Study Variables This study is a secondary data analysis of the 2002 and 2003 National Health Interview Survey. 15 The independent variables are age, race, gender, parental income, region, parental education, health status, health care utilization, and source of health care; and the outcome variables are health insurance coverage and asthma management plan status. Age is categorized as less than 5 years of age and 5 to 17 years of age. Race is classified as Hispanic, non-hispanic white, and non-hispanic black. Gender is classified as male and female. Income is categorized as $1 to $14 999, $15 000 to $24 999, $25 000 to $44 999, $45 000 to $64 999, and $65 000 and more.region is identified as northeast, midwest, South, and west. Parental education is identified as no high school diploma; high school diploma/general Education Development recipient; some college, no degree; associates degree; bachelors degree and above. Health status is defined as better, worse, or about the same. Health care utilization is measured by examining the frequency of general physician and respiratory therapist visits. Source of care is measured by the common location in which health care services are received: doctor s office, clinic or health center, emergency room, outpatient department, or does not get preventive care anywhere. Health insurance coverage is classified as Medicaid, Children s Health Insurance Program (CHIP), private health insurance, Tricare, and uninsured. Asthma management is defined by the question in the National Health Interview Survey: Has a doctor or other health professional ever given the child an asthma management plan? Additional variables of interest included: advised to change environment for asthma, ever taken preventive asthma medications, respiratory therapist s visits, and emergency department visit due to asthma. Data Management The data was initially processed with Statistical Analysis Software (SAS) 8.2. 16 The data was further analyzed using SAS-callable SUDAAN to account for the complex multistage sampling design of the National Health Interview Survey. 17 A final combined data set was created from each individual year of data that was merged. If the response to a question included don t know or was refused, responses were set to missing. Institutional review board exemption from the University of South Carolina was granted. Statistical Data Analysis Parametric testing using univariate/bivariate/multivariate analysis was performed to examine health insurance coverage and asthma management plan physician recommendations among children in the United States. In preliminary analysis, frequency distributions and univariate statistics were measured to describe the population (PROC FREQ in SAS). The c 2 test statistic was used to test for independence among the variables. Distribution of variables according to age, race, gender, income, region, parental education, health status, health care utilization, health insurance coverage, and asthma management plan status are presented with p values and proportions with 95% confidence intervals (CIs) and odds ratios (ORs). Bivariate analyses were used to compare health insurance coverage and asthma management plans with the independent variables using the c 2 statistics test. The bivariate statistics provided the first indication of the differences and associations among the variables. Multivariate analysis for each outcome variable was JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 7, JULY 2010 557

used to adjust for other demographic factors and dichotomous variables. The estimates produced in this study were weighted to present the US population and to adjust for potential survey response bias. For all analyses, statistical significance was set at P <.05. The fitting of the multivariate models was based on empirical and conceptual considerations. Each model was adjusted for race, age, gender, health insurance status, and health care utilization. The theoretical framework proposed by Figure was replicated to decide which variables to consider in the model by including predisposing, enabling, and need variables in the multivariate models. To construct efficient models, the stepwise regression procedure was used to identify demographic predictors for each outcome. In the stepwise regression procedure, all variables were considered and then removed if the p >.05. RESULTS The 2002 and 2003 original weighted sample population consisted of approximately 13 000 children, and a subset of the data was conducted to account for the 3102 children identified as having asthma based on the survey question, Has a doctor or other health professional ever told you that your child has asthma? ; then a follow-up question, Does your child still have asthma? led to a final study population of 2110 children. The study population included Hispanic (22.92%), non-hispanic white (50.96%), and non-hispanic black (26.12%) children. The gender distribution of the children was 57.11% male and 42.89% female. The percentage of children under 5 years of age was 28.90% and for children 5 to 17 years of age was 71.10%. Overall, the most identified family income was $1 to 14 000 (29.58%), respectively. The south had the largest percentage of observations at 36.30%, followed by the midwest (22.70%), northeast (21.23%), and west (19.76%). Parents were most likely to report a high school graduate for the highest level of education mothers, 29.01%, and fathers, 30.28%. Among the children in this study, the majority of them had seen a general doctor in the past 12 months (87.93%). The percentage of children with asthma in this study that had an asthma episode in the past 12 months was 62.42%. Those who reported ever taken preventive asthma medications were 57.19%. Half of the participants in this study (50.96%) reported being advised to change their environment due to their asthma. The percentage of children with asthma that had private insurance was 53.59%; Medicaid, 25.49%; CHIP, 4.90%; Tricare, 1.76%; and uninsured, 6.85%. The majority of the study participants reported not having an asthma management plan (59.00%) (Table 1). In the bivariate analysis, marginal statistical Figure. Framework for Study of Access Aday and Andersen Health Policy Financing Education Manpower Organization Characteristics of Health System Resources Organization Entry Structure Utilization of Health Services Type Site Purpose Time interval Characteristics of Population at Risk Predisposing Enabling Need Customer Satisfaction Convenience Cost Courtesy Quality 558 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 7, JULY 2010

significance was found in the logistic regression model, where white children were more likely to report having an asthma management plan compared to black and Hispanic children (OR, 1.25; p =.0648). In this study, children who experienced an asthma episode in the past 12 months were less likely to have an asthma management plan (OR, 0.51; p <.0001). Children in this study that had private insurance were less likely to have an asthma management plan (OR,.72; p =.0012). Statistical significance was found among children that reported having CHIP being twice as likely to have an asthma management plan (OR, 2.42; p =.0007). Children in this study who were advised to change their environment due to their asthma conditions were less likely to have an asthma management plan (OR, 0.27; p <.0001; Table 2). In the multivariate analysis, whites were significantly more likely than non-hispanic blacks and Hispanics to have an asthma management plan (OR, 1.66; p =.0031). Children who had an asthma episode in the past 12 months were less likely to have an asthma management plan (OR, 0.62; p =.0002). Children in this study who reported CHIP coverage were twice as likely to have an asthma management plan (OR, 2.67; p =.0004). Children who were advised to change their environment due to their asthma condition were less likely to have an asthma management plan (OR, 0.22; p <.0001). Children who were using preventive asthma medications were significantly less likely to have an asthma management plan (OR, 0.32; p <.0001; Table 3). Table 1. Demographic Characteristics of Children With Asthma (n = 2110), 2002-2003 Characteristics Frequency (n) % Race White 1036 50.96 Black 531 26.12 Hispanic 466 22.92 Total 2033 100 Age, y <5 633 28.90 5-17 1477 71.10 Income $1-$14 999 277 29.58 $15 000-$24 999 230 14.82 $25 000-$44 999 401 24.56 $45 000-$64 999 243 14.08 $65 000 483 16.96 Total 1633 100 Education, mother No high school diploma 327 16.91 High school graduate, General Education Development recipient 561 29.01 Some college, no degree 442 22.85 Associate degree 233 12.05 Bachelor s degree and above 371 19.18 Total 1934 100 Education, father No high school diploma 232 17.87 High school graduate, General Education Development recipient 393 30.28 Some college, no degree 235 18.10 Associate degree 107 8.24 Bachelor s degree and above 331 25.50 Total 1298 100 Region Northeast 448 21.23 Midwest 479 22.70 South 766 36.30 West 417 19.76 Insurance status Private 1193 55.59 Medicaid 561 25.49 Tricare 37 1.76 Uninsured 191 6.85 % JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 7, JULY 2010 559

DISCUSSION Findings from this study indicate that black and Hispanic children with asthma are less likely to have an asthma management plan. Statistical significance was not found among children with private insurance being more likely to have an asthma management plan. In particular, children who reported having CHIP coverage were twice as likely than privately insured children to have an asthma management plan (OR, 2.28; p =.0066). Surprisingly, in this study, children who had private insurance were less likely to have an asthma management plan. The explanation for the findings regarding insurance type and asthma management plan status is unclear, as the opposite trend is usually observed. 9 Public health insurance programs may be gaining more widespread acceptance by private practitioners in the United States, which may have led to the children insured by CHIP being more likely to have an asthma management plan. 9 Having private insurance did not result in higher rates of having an asthma management plan, as expected; however, children with private insurance are possibly healthier overall than children who have public insurance. Our findings indicate that health insurance type is a predictor in physician-recommended asthma management plans. Table 1. Demographic Characteristics of Children With Asthma (n = 2110), 2002-2003 (cont) Characteristics Frequency (n) % Health status Better 843 21.23 Worse 91 22.70 About the same 1172 36.30 General doctor visits in the past 12 mo Yes 1850 87.93 No 254 12.07 Total 2104 100 Use of preventive asthma medications in the past 12 mo Yes 1201 57.19 No 899 42.81 Advised to change environment due to asthma Yes 1040 50.96 No 1001 49.04 Total 2041 100 Provided an asthma management plan Yes 850 41.00 No 1223 59.00 Total 2073 100 Table 2. Characteristics of Children With an Asthma Management Plan (Bivariate) Odds Ratio 95% Confidence Interval P Value Race White 1.25 (0.99-1.57) a.0648 a Black 1.00 1.00-1.00 Hispanic 0.96 (0.72-1.27) Asthma episode in the past 12 mo Yes 0.51 (0.42-0.63) a <.0001 a Insurance status Private Yes 0.72 (0.59-0.88) a.0012 a Children s Health Insurance Program Yes 2.42 (1.45-4.02) a.0007 a Advised to change environment due to asthma Yes 0.27 (0.22-0.33) a <.0001 a a Statistically significant at <.05. 560 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 7, JULY 2010

Table 3. Characteristics of Children With an Asthma Management Plan (Multivariate) Characteristics Odds Ratio 95% Confidence Interval P Value Race White 1.66 (1.20-2.30).0031 a Black 1.00 1.00-1.00 Hispanic 1.06 (0.72-1.55) Asthma episode in the past 12 mo Yes 0.62 (0.48-0.80) a <.0001 a Insurance status, Children s Health Insurance Program Yes 2.67 (1.56-4.56) a.0004 a Advised to change environment due to asthma Yes 0.22 (0.17-0.29) a <.0001 a Use of preventive asthma medications Yes 0.32 (0.25-0.41) a <.0001 a a Statistically significant at <.05. The use of the National Health Interview Survey provided a large nationally representative sample, along with the survey s accuracy and reliability, is a major strength of this study. The use of SUDAAN for all data analyses increased the preciseness and validity of the study results. Potential limitations of the study are that it relied solely on parental reporting of the asthma status of the child without analyzing medical records, which could lead to a potential overestimation or underestimation bias. Some children may have been provided an asthma management plan that the parents did not recall or chose not to use, or the physician may have not specified the appropriate use for the plan. Better assessment of asthma management plan recommendations and type of health insurance for children with asthma will have to be considered in the future. Despite the many medical milestones and accomplishments of the American medical system, there is a disproportionate number of health disparities that still exist, and this issue is a major health policy priority. Our finding that children covered by CHIP were more likely to have an asthma management plan is encouraging. The CHIP program has provided needed health resources for many poor and underserved children since its inception in 1997. However, CHIP did not receive long-term authorization in 2007, after initial authorization expired. CHIP did receive additional funding at the 2007 level until 2009, but some believe this level of funding falls below need, thus creating more uninsured and underserved children. Policies to address these issues should address fundamental health system changes. The study findings warrant further investigation into the practices of physicians in recommending an asthma management plan. This study points to the need to improve the management of children with asthma. Mandating all insurers provide an asthma management plan to children with asthma may reduce the race-based inequities and differences in insurance type in having an asthma management plan. References 1. Gergen P. Understanding the economic burden of asthma. J Allergy Clin Immunol. 2001;107:S445-S448. 2. 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