Original article
Asthma, lower airway diseases
Prescription fill patterns in underserved children with asthma receiving subspecialty care

https://doi.org/10.1016/j.anai.2013.06.009Get rights and content

Abstract

Background

Children with asthma receiving specialty care have been found to have improved asthma outcomes. However, these outcomes can be adversely affected by poor adherence with controller medications.

Objective

To analyze pharmacy fill patterns as a measure of primary adherence in a group of underserved minority children receiving allergy subspecialty care.

Methods

As part of a larger 18-month nebulizer use study in underserved children (ages 2-8 years) with persistent asthma, 53 children were recruited from an urban allergy practice. Pharmacy records were compared with prescribing records for all asthma medications.

Results

Allergist controller prescriptions were written in 30-day quantities with refills and short-acting β-agonists (SABAs) with no refills. Only 49.1% of inhaled corticosteroid (ICS), 49.5% of combination ICS and long-acting β-agonist, and 64.5% of leukotriene modifier (LTM) initial and refill prescriptions were ever filled during the 18-month period. A mean of 5.1 refills (range, 0-14) for SABAs were obtained during 18 months, although only 1.28 SABA prescriptions were prescribed by the allergist. Mean times between first asthma prescription and actual filling were 30 days (range, 0-177 days) for ICSs, 26.6 days (range, 0-156 days) for LTMs, and 16.8 days (range, 0-139 days) for SABAs.

Conclusion

Underserved children with asthma receiving allergy subspecialty care suboptimally filled controller prescriptions, yet filled abundant rescue medications from other prescribers. Limiting albuterol prescriptions to one canister without additional refills may provide an opportunity to monitor fill rates of both rescue and controller medications and provide education to patients about appropriate use of medications to improve adherence.

Introduction

Asthma is the most common chronic disorder in pediatrics, affecting more than 1 of 10 children in Maryland1 and as many as 1 of 5 children in Baltimore, Maryland.2 The current asthma treatment guidelines recommend that persistent asthma should be treated as a chronic illness with daily inhaled steroid therapy rather than urgently, when exacerbations occur.3 Improved asthma outcomes are clearly related to asthma controller medication use.[4], [5], [6] Adherence to controller asthma medication regimens is less than ideal, especially in underserved populations.[7], [8], [9] Theories as to the causes of secondary or tertiary nonadherence are well represented in the literature. Primary nonadherence, or not obtaining or filling the medication as prescribed, is not well understood. Adherence may be affected by many variables, including access to quality care[10], [11], [12] nonadherence to asthma guidelines by prescribing physicians,[13], [14], [15] patient-physician relationships,16 cost of asthma medications,[17], [18], [19] and patient- and caregiver-related medication preferences, beliefs or misconceptions.[20], [21], [22] The purpose of this study is to evaluate primary nonadherence in underserved children with asthma cared for by an allergist by determining whether asthma medication prescriptions that are written are ever filled, whether prescriptions for controllers are refilled, and whether families deploy a “selective” filling pattern.

Section snippets

Methods

Data for this study were collected from a convenience sample of patients treated in an urban subspecialty allergy practice and enrolled in a nebulizer education intervention trial.23Briefly, the nebulizer study evaluated the effect of a nebulizer use–focused asthma education intervention on asthma outcomes in inner-city children 2 to 8 years old with persistent asthma. Children were defined as having persistent asthma based on national guideline3 criteria using caregiver-reported daytime and

Results

Overall, 53 of 55 children receiving allergy care in the nebulizer study were enrolled. Two children were not included because of missing pharmacy data. No significant differences were found in baseline characteristics between the 2 children who were excluded and the overall study group. Children had a mean age of 4.6 years (range, 2-8 years) and were primarily male (53%), African American (81%), and Medicaid insured (72%). All patients had persistent asthma, with a mean of 2.7 (range, 1-7)

Discussion

Medicaid insured children with asthma have high asthma-related morbidity and mortality, and low adherence with controller medication therapy significantly affects asthma control.[5], [6], [9] Strikingly, in our sample of Medicaid insured children with poorly controlled asthma seen by an allergy subspecialist during an 18-month study period, nearly 30% of all prescriptions written by an allergist were never filled. Higher rates of primary nonadherence (up to 40%) for controller medication

Acknowledgment

We thank Amanda Manning for her assistance with data collection and entry for this study.

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    Disclosers: The author have no conflicts of interest to disclose.

    Funding Source: This study was funded by National Institute of Nursing Research grant NIH NR 05060.

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