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

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

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

Child and Adult United States and Arizona lifetime and period (current) asthma prevalence,

Mean United States Lifetime and Period (Current) Asthma Prevalence for Children by Race,

Emergency Department and Inpatient Trends in Asthma  Arizona in  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  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, Tormala et al., 2010

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, National Institute of Allergy and Infectious Disease, Boudreaux, Emond, Clark, & Camargo, 2003

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 Hispanic Non-Hispanic White Stranges, Coffey, & Andrews, Nash, Childs, & Kelleher, Lozano, Connell, & Koepsell, 1995 Yes No {

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?

Methods Population defined: -Continuous enrollment -Resident Maricopa County -Age 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

Characteristics of All Children Continuously Enrolled in AHCCCS/Arizona Medicaid in Maricopa County and Number and Percent With Asthma

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

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

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…

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…

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

A Closer Look at Race (using Caucasian race as referent group)… Race/EthnicityOdds Ratio 95% CIP value Hispanic p=0.03 African-American p= Native-American p=0.28 Asian-American/ Pacific Islander p=0.17

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)

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

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

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

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)

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., Mosen et al., 2005

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 ( )  Action

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 ( )  Action  Questions

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  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),  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.

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),  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,  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.