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Accessibility to Inhaled Cortico-steroids among Adults with Chronic Asthma:

Accessibility to Inhaled Cortico-steroids among Adults with Chronic Asthma: AN IMPACT OF THE UNIVERSAL HEALTH CARE COVERAGE POLICY. Chulaporn Limwattananon, MPharm, MSc, PhD * Supon Limwattananon, MPHM, PhD * Supasit Pannarunothai, MD, PhD **

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Accessibility to Inhaled Cortico-steroids among Adults with Chronic Asthma:

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  1. Accessibility to Inhaled Cortico-steroids among Adults with Chronic Asthma: AN IMPACT OF THE UNIVERSAL HEALTH CARE COVERAGE POLICY • Chulaporn Limwattananon, MPharm, MSc, PhD * • Supon Limwattananon, MPHM, PhD * • Supasit Pannarunothai, MD, PhD ** • * Faculty of Pharmaceutical Sciences, Khon Kaen University • ** Center for Health Equity Monitoring, Naresuan University • - Thailand

  2. Introduction • Asthma: a chronic illness in 5-9% of adults(Boonsawat et al., 2002) • and 10-13% of children (Vichyanond et al., 1998)in Thailand • ICS: the most effective controller for persistent asthma • (NHLBI, 2002) • Low rate of ICS use: 6.6% of adults w/ asthma,a 4-province survey in Thailand) • The 2002 UC policy: To improve an access to necessary care • for the poor and the uninsured, rest of population

  3. Before 2002 After 2001 LIC UCLIC (Low-Income Card)no copayment required UCROP Uninsured,30-Baht copayment per visit rest of population (ROP) ROP CSMBSCSMBS (Civil Servant Med. Benefit) SSSSSS (Social Security) Oct. 2001 UC policy

  4. Major Health Insurance Schemes Scheme Payment mechanism CSMBS Fee for service (Civil Servant (Retrospective, open-end, cost-based) Medical Benefit Scheme) SSS Capitation (Social Security Scheme)(Prospective, close-end, risk-based) UC Capitation for outpatient visit (Universal Coverage)+ DRG for high-cost inpatient care LIC (defunct since 2002) Global budget (Low-Income Card)+ DRG for high-cost inpatient care

  5. Objectives To determine the propensity to receive ICS as related to major health insurance schemes of adults with chronic asthma, taking into account of variations in patient demographics and severity of asthma

  6. Study Population Settings: 17 MOPH-provincial hospitals in 4 regions of Thailand (secondary and tertiary acute care) Sample: A panel of 6,176 adult cohorts, aged > 18 years, receiving antiasthmatics for 3 consecutive years (2000 - 2002)

  7. Study Design & Analysis • Retrospective, secondary analysis of electronic databases • of drug use and patient hospitalization • Statistical analysis:Logistic regression model * • Effect of the UC policy on UC recipients was captured by the • interaction between year of drug use and insurance scheme: Year2002 x UCLIC • Year2002 x UCROP • * Control for the underlying differences in propensity of ICS use due to • Patient demographics (age, gender) • Prior hospitalization and use of rescue medicine due to asthma • (proxy for severity of asthma) • Hospital settings (proxy for prescribing practice styles)

  8. The Study Antiasthmatics Inhaled cortico-steroids (ICS): beclomethasone, budesonide, budesonide plus formoterol, fluticasone, fluticasone plus salmeterol Inhaled bronchodilators (BD-INH): formoterol, ipratropium plus fenoterol, ipratropium plus salbutamol, procaterol, salbutamol, salmeterol, terbutaline Oral bronchodilators (BD): aminophylline/theophylline, bambuterol, procaterol, salbutamol, terbutaline

  9. Recipients of Anti-asthmatics CSMBSUCLICUCROPROPSSS (N = 1,668) (N = 2,553)(N = 866)(N = 465)(N = 624) Fiscal year 2001 Inhaled corticosteroids 40.5%25.3%47.7%34.4%39.4% Bronchodilators only - Inhaled 3.7% 1.8% 3.0% 4.9% 5.6% - Oral 25.1% 25.7% 13.7% 21.9% 13.5% - Inhaled and oral 30.8% 47.2% 35.6% 38.7% 41.5% Fiscal year 2002 Inhaled corticosteroids 41.2%25.0%50.0%27.1%39.3% Bronchodilators only - Inhaled 4.7% 2.6% 1.6% 9.5% 7.7% - Oral 25.6% 26.3% 11.8% 27.1% 12.7% - Inhaled and oral 28.5% 46.0% 36.6% 36.3% 40.4%

  10. Baseline Characteristics of Asthma Patients ICS Non-ICS P-value recipients recipients Fiscal year 2001(N = 2,139) (N = 4,037) Age 18 – 35 years 18.3% 11.1% < 0.001 Age 36 – 49 years 31.4% 17.9% Age 50 + years 50.3% 71.0% Male 43.6% 52.5% < 0.001 Prior hospitalization 14.2% 4.6% < 0.001 Prior use of 28.8% 22.2% < 0.001 nebulizing beta-2 agonists

  11. Baseline Characteristics of Asthma Patients ICS Non-ICS P-value recipients recipients Fiscal year 2002(N = 2,130) (N = 4,046) Age 18 – 35 years 17.6% 11.5% < 0.001 Age 36 – 49 years 30.8% 18.2% Age 50 + years 51.6% 70.3% Male 44.3% 52.1% < 0.001 Prior hospitalization 12.8% 4.4% < 0.001 Prior use of 33.4% 24.7% < 0.001 nebulizing beta-2 agonists

  12. Prior Use of Hospital Care for Asthma CSMBSUCLICUCROPROPSSS (N = 1,668)(N = 2,553)(N = 866)(N = 465)(N = 624) Hospitalization in 2000 No admission 92.8% 93.3% 88.3% 92.0% 90.5% One admission5.0%4.4%7.4%5.6%6.7% More than once2.2%2.3%4.3%2.4%2.7% Median LOS 4 days 2 days 2 days 2 days 2 days Hospitalization in 2001 No admission 93.4%93.9% 88.9%93.8% 90.5% One admission 4.6%4.2%8.2%3.9%6.4% More than once 2.0%1.8%2.9%2.4%3.0% Median LOS 4 days 2.5 days 2 days 2 days 3 days

  13. Propensity to Receive ICS (Competing Models) Model with interaction terms Main effect model Coefficienta P value Coefficienta P value Age 36 – 49 years b 0.007 0.916 0.007 0.915 Age 50+ years b - 0.825 < 0.001 - 0.824 < 0.001 Male - 0.112 0.009 - 0.112 0.009 Prior hospitalization 1.098 < 0.001 1.099 < 0.001 Prior use of 0.523 < 0.001 0.521 < 0.001 nebulizing beta-2 agonists CSMBS c 0.413 < 0.001 0.415 < 0.001 UCLIC c - 0.136 0.206 - 0.175 0.027 UCROP c 0.351 0.003 0.385 < 0.001 ROP c 0.133 0.355 - 0.070 0.501 Year 2002 - 0.229 0.242 - 0.249 0.093 CSMBS x Year 2002 0.004 0.979 UCLIC x Year 2002 - 0.080 0.591 UCROP x Year 2002 0.067 0.695 ROP x Year 2002 - 0.422 0.042 a Based on logistic regression analysis, adjusted for hospital indicators b Age of 18-35 years as the reference category c SSS as the reference category Statistical non-significance

  14. Propensity to Receive ICS (Final Model) Odds ratioa P value 95% CI Age 36 – 49 years b 1.01 0.915 0.88 – 1.15 Age 50+ years b 0.44 < 0.001 0.39 – 0.50 Male 0.89 0.009 0.82 – 0.97 Prior hospitalization 3.00 < 0.001 2.57 - 3.50 Prior use of 1.68 < 0.001 1.52 - 1.86 nebulizing beta-2 agonists CSMBS c 1.51 < 0.001 1.29 - 1.77 UCLIC c 0.84 0.026 0.72 - 0.98 UCROP c 1.47 < 0.001 1.24 - 1.73 ROP c 0.93 0.492 0.76 - 1.14 a Based on logistic regression analysis, adjusted for years of drug use and hospital indicators b Age of 18-35 years as the reference category c SSS as the reference category

  15. Propensity to Receive ICS Risk CSMB UCROP SSS ROP UCLIC No prior hospitalization nor prior rescue medication With prior hospitalization and prior rescue medication CSMB UCROP SSS ROP UCLIC Year 2001 2002 2001 2002

  16. Conclusion • Need for ICS was not met in certain groups of chronic asthma. • UC policy in 2002 did not improve ICS accessibility for UC recipients • who in 2001 had been covered by LIC (i.e., the UCLIC group). • Patients covered by a generous scheme like CSMB were better off • in an access to ICS. • The facts that the propensity to receive ICS in the UCROP group • was comparable to CSMB but far better than the UCLIC counterpart • are worth to be further examined.

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