1. THE ROLE OF ACCESS(AHCCCS): ACUTE ASTHMA CARE UTILIZATION IN A 2008 ARIZONA MEDICAID POPULATION Zachary Ortiz, MaEd UA COM-P MD/MPH, Class of 2012

2. Overview  Background of asthma  Lifetime prevalence  Period prevalence  Demographics of acute service utilization  Methods  Results  Discussion  Limitations  Future directions

3. Lifetime prevalence of children (≤17yrs) in Arizona, United States, 2005—2009 (Tormala et al., 2010)

4. Child and Adult United States and Arizona lifetime and period (current) asthma prevalence, 2005-2009

5. Mean United States Lifetime and Period (Current) Asthma Prevalence for Children by Race, 2005-2009

6. Emergency Department and Inpatient Trends in Asthma  Arizona in 2004 1  7,250 days of hospitalization of persons under 21 years old with primary complications due to asthma  50% of these in the K-12 age group  $24 million in services, much of which is absorbed by tax payers  Arizona in 2009 2  25,893 emergency department (ED) visits 45% in children ≤ 15 yo  2,998 inpatient (IP) events 36% in children ≤ 15 yo 1 Arizona Comprehensive Asthma Control Plan, 2005 2 Tormala et al., 2010

7. Racial Disparities in Asthma— Acute Care Seeking  Hispanic hospitalization/ inpatient (IP) 15.5/10,000 vs. non- Hispanic white rates of 8.9 per 10,000 1  African-Americans three times as likely as non-Hispanic whites to be hospitalized for asthma 2  Three times more likely to die from asthma 2  African-American and Hispanic children more likely to ever have been hospitalized for asthma, median # visits, % admitted and % using ED for medications 3 1 Stranges, Coffey, & Andrews, 2008 2 National Institute of Allergy and Infectious Disease, 2001 3 Boudreaux, Emond, Clark, & Camargo, 2003

8. Is socioeconomic status a confounder in the observed differences between racial groups?  Among Medicaid children, African-American children were at increased odds of being “high users” or “extra high users” of the ED or IP 2  African-Americans on Medicaid in Seattle, WA had greater odds of IP and ED visit, less outpatient visits, 24% greater payments for asthma services 3 Race<25%ile earnings>75%ile Hispanic21.711.0 Non-Hispanic White12.37.3 1 1 Stranges, Coffey, & Andrews, 2008 2 Nash, Childs, & Kelleher, 1999 3 Lozano, Connell, & Koepsell, 1995 Yes No {

9. Central Questions  Are there race, gender or age disparities in acute asthma care seeking behavior amongst pediatric AHCCCS patients with asthma?  Contrast with epidemiology of who gets asthma, and acute care seeking where socioeconomic might be confounding  Hypothesis: If socioeconomic barriers to preventive asthma care are reduced through continuous enrollment in AHCCCS/Medicaid in 2007, then no significant between-group differences in inpatient (IP) or emergency department (ED) service utilization will occur with respect to age, gender and race in 2008 (if SES is a confounder b/w race/ethnicity driving care-seeking behavior)  If differences exist, what could be some of the contributing factors (policy/public health implications)?  What variables (beliefs about asthma, distrust of medical professionals, extreme poverty, poor medical education etc) are influencing acute care seeking behavior?

10. Methods 2007 2008 2009 Population defined: -Continuous enrollment -Resident Maricopa County -Age 5-17 -Met HEDIS definition of asthma Study period: -# asthma-related emergency department visits and hospitalizations -Captured gender, age and race (and event by season) HEDIS definition: -1 asthma related inpatient (IP) admission or 4 asthma medication dispensing events or 4 outpatient (OP) visits + 2 asthma medication dispensing events Data collected: -ED and IP visits by 1) Age 2) School Age 3) Race/ethnicity

11. Characteristics of All Children Continuously Enrolled in AHCCCS/Arizona Medicaid in Maricopa County 2007-2008 and Number and Percent With Asthma

12. Histogram of for a) Total Visits (IP and ED) and b) Total Visits (ED and IP) if Any Visits ≥ 1 in Children With Asthma in 2008  Zero-inflated  Non-normally distributed

13. Chi 2 ( χ 2 ) Analysis in Children With Asthma and At Least One Visit (ED or IP) for Asthma by Gender… Conclusion: No significant association exists between gender and utilization of asthma services

14. Conclusion: A significant association exists between school age and utilization of asthma services Chi 2 ( χ 2 ) Analysis in Children With Asthma and At Least One Visit (ED or IP) for Asthma by School Age…

15. Conclusion: A significant association exists between race and utilization of asthma services Chi 2 ( χ 2 ) Analysis in Children With Asthma and At Least One Visit (ED or IP) for Asthma by Race…

16. A Closer Look at School Age (using elementary as referent group)

17. A Closer Look at Race (using Caucasian race as referent group)… Race/EthnicityOdds Ratio 95% CIP value Hispanic1.31.2-1.7p=0.03 African-American2.01.5-2.8p=0.0001 Native-American1.50.7-3.0p=0.28 Asian-American/ Pacific Islander 0.270.01-1.65p=0.17

18. Odds Ratios and 95% Confidence Interval that a Child With Asthma Experienced at Least One Asthma Event (ED or IP) by Race in…  Elementary School-Aged Individuals (Caucasian is Index Race)

19. …by Junior High School-Aged Individuals (Caucasian is Index Race)

20. …by High School-Aged Individuals (Caucasian is Index Race)

21. Results summarized  Jnr high (OR=0.43) and HS (OR=0.56) were less likely to have any ED or IP event compared to elementary  Despite theoretically equal access(AHCCCS) to healthcare, disparities exist between race/ethnic groups with respect to acute care seeking behaviors in 2008  Overall—  Hispanic children 1.3 odds of any ED/IP event  African-American children 2.0 odds of any ED/IP event  African-American elementary (2.4) and high-school aged African-American (1.9) and Native-American high-school aged (3.4) individuals had increased odds of ED/IP events

22. Discussion  School-age conclusions expected  Physiology of asthma and airway diameter 1  Factors accounting for differences amongst race/ethnicity:  Race/ethnic cultural difference in perception of asthma (acute vs. chronic dz), or education received in asthma  Distrust of physicians  ↓ primary care visits  ↑ acute care seeking  AHCCCS enrollment doesn’t account for extreme poverty (which may be correlated with race)  Med co-pays, transportation, home trigger mitigation 1 L. J. Akinbami & Schoendorf, 2002)

23. Limitations  Data are observational, retrospective  HEDIS is a surrogate for true asthma prevalence  Demonstrated to lack specificity and 1 year lead in period suboptimal 1,2  Classification of “Hispanic” 1 Cabana et al., 2004 2 Mosen et al., 2005

24. Future Directions  Prospective study of similar population  De-aggregated race data  Obtain additional SES information, income levels, educational attainment of parents, medical trust/barriers to care surveys  Confirmatory studies of using these methods in this population with annual data (2009-2011)  Action

25. Future Directions  Prospective study of similar population  De-aggregated race data  Obtain additional SES information, income levels, educational attainment of parents, medical trust/barriers to care surveys  Confirmatory studies of using these methods in this population with annual data (2009-2011)  Action  Questions

26. References I  Akinbami, L. J., & Schoendorf, K. C. (2002). Trends in childhood asthma: Prevalence, health care utilization, and mortality. Pediatrics, 110(2), 315.  Arizona Department of Health Services. (2004). Arizona comprehensive asthma control plan Retrieved from www.tobaccofreearizona.com/reports/pdf/asthma-control.pdf www.tobaccofreearizona.com/reports/pdf/asthma-control.pdf  Boudreaux, E. D., Emond, S. D., Clark, S., & Camargo, C. A. (2003). Race/ethnicity and asthma among children presenting to the emergency department: Differences in disease severity and management. Pediatrics, 111(5), e615.  Cabana, M. D., Slish, K. K., Nan, B., & Clark, N. M. (2004). Limits of the HEDIS criteria in determining asthma severity for children. Pediatrics, 114(4), 1049.  Lozano, P., Connell, F. A., & Koepsell, T. D. (1995). Use of health services by african-american children with asthma on medicaid. JAMA: The Journal of the American Medical Association, 274(6), 469.

27. References II  Mosen, D. M., Macy, E., Schatz, M., Mendoza, G., Stibolt, T. B., McGaw, J., et al. (2005). How well do the HEDIS asthma inclusion criteria identify persistent asthma. Am J Manag Care, 11(10), 650- 654.  Nash, D. R., Childs, G. E., & Kelleher, K. J. (1999). A cohort study of resource use by medicaid children with asthma. Pediatrics, 104(2), 310.  National Institute of Allergy and Infectious Disease. (2001). Asthma-- A concern for minority populations, NIAID fact sheet  Stranges, E., Coffey, R., & Andrews, R. M. (2008). Potentially preventable hospitalizations among hispanic adults, 2006.  Tormala, W., Shetty, G., Valenzuela, K., & Ortiz, Z. (2010). The 2009 arizona asthma burden reportArizona Department of Health Services, Bureau of Tobacco and Chronic Disease.