P1254325908PcJSl - PowerPoint PPT Presentation

Title: P1254325908PcJSl


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 CSMBS CSMBS (Civ
il Servant Med. Benefit) SSS SSS (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 gt 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
CSMBS UCLIC UCROP ROP
SSS (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 lt 0.001 Age 36 49
years 31.4 17.9 Age 50 years 50.3 71.0
Male 43.6 52.5 lt 0.001 Prior
hospitalization 14.2 4.6 lt 0.001 Prior use
of 28.8 22.2 lt 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 lt 0.001 Age 36 49
years 30.8 18.2 Age 50 years 51.6 70.3
Male 44.3 52.1 lt 0.001 Prior
hospitalization 12.8 4.4 lt 0.001 Prior use
of 33.4 24.7 lt 0.001 nebulizing beta-2
agonists
12
Prior Use of Hospital Care for Asthma
CSMBS UCLIC UCROP ROP
SSS (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 admission 5.0
4.4 7.4 5.6 6.7 More than
once 2.2 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 lt
0.001 - 0.824 lt 0.001 Male - 0.112
0.009 - 0.112 0.009 Prior
hospitalization 1.098 lt 0.001
1.099 lt 0.001 Prior use of 0.523 lt
0.001 0.521 lt 0.001 nebulizing beta-2
agonists CSMBS c 0.413 lt 0.001
0.415 lt 0.001 UCLIC c -
0.136 0.206 - 0.175 0.027 UCROP
c 0.351 0.003 0.385 lt
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 lt 0.001 0.39 0.50 Male 0.89
0.009 0.82 0.97 Prior hospitalization 3.00
lt 0.001 2.57 - 3.50 Prior use of 1.68 lt
0.001 1.52 - 1.86 nebulizing beta-2
agonists CSMBS c 1.51 lt 0.001 1.29 -
1.77 UCLIC c 0.84 0.026 0.72 - 0.98 UCROP
c 1.47 lt 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.