Original articleAsthma, lower airway diseasesPrescription fill patterns in underserved children with asthma receiving subspecialty care
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.
References (37)
- et al.
Environmental allergens and asthma in urban elementary schools
Ann Allergy Asthma Immunol
(2003) - et al.
Use of asthma medication dispensing patterns to predict risk of adverse health outcomes: a study of Medicaid-insured children in managed care programs
Ann Allergy Asthma Immunol
(2004) - et al.
Physician adherence to the national asthma prescribing guidelines: evidence from national outpatient survey data in the United States
Ann Allergy Asthma Immunol
(2008) - et al.
Barriers to anti-inflammatory medication use in childhood asthma
Ambul Pediatr
(2003) - et al.
Parental beliefs about medications and medication adherence among urban children with asthma
Ambul Pediatr
(2005) - et al.
Asthma patients' self-reported behaviours toward inhaled corticosteroids
Respir Med
(2009) - et al.
Patients with asthma who do not fill their inhaled corticosteroids: a study of primary nonadherence
J Allergy Clin Immunol
(2007) - et al.
Telephoning the patient's pharmacy to assess adherence with asthma medications by measuring refill rate for prescriptions
J Pediatr
(2000) - et al.
Short-acting beta-agonist prescription fills as a marker for asthma morbidity
Chest
(2005) - et al.
Concordance of Medicaid and pharmacy record data in inner-city children with asthma
Contemp Clin Trials
(2008)
Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007
J Allergy Clin Immunol
The role of inhaled corticosteroids and montelukast in children with mild-moderate asthma: results of a systematic review with meta-analysis
Arch Dis Child
Adherence rate to inhaled corticosteroids and their impact on asthma control
Allergy
Adherence to pediatric asthma treatment in economically disadvantaged African-American children and adolescents: an application of growth curve analysis
J Pediatr Psychol
Patterns of inhaled antiinflammatory medication use in young underserved children with asthma
Pediatrics
Relationship of adherence to pediatric asthma morbidity among inner-city children
Pediatrics
Urban minority children with asthma: substantial morbidity, compromised quality and access to specialists, and the importance of poverty and specialty care
J Asthma
Cited by (24)
Caregiver Depressive Symptoms and Primary Medication Nonadherence in Children With Asthma
2022, Journal of Pediatric Health CareCitation Excerpt :The caregiver must obtain prescriptions from the child's health care provider, collect the medications from the pharmacy, and administer the medications correctly (Vrijens et al., 2012). Although there may be barriers in all steps of adherence, less is known about primary medication nonadherence (i.e., failure to fill a new prescription; Bellin et al., 2018; Bollinger et al., 2013). Factors associated with primary medication nonadherence are understudied but may include insurance/medication cost, health behaviors, and health beliefs (Bellin et al., 2018; Hensley et al., 2018; Williams et al., 2007b).
Chronic stress and asthma in adolescents
2020, Annals of Allergy, Asthma and ImmunologyCitation Excerpt :Cognitively, adolescents move from concrete thinking to abstract, multidimensional, hypothetical, and planned thinking.7 All these changes make handling a chronic disease, such as asthma, a challenge, as evidenced by their poor understanding of the disease and poor adherence to treatment.8-11 Moreover, adolescents start facing or perceiving an increased amount of stressors that may be prove difficult to handle.12
Characteristics of inner-city children with life-threatening asthma
2019, Annals of Allergy, Asthma and ImmunologyCitation Excerpt :The fill rates for controller therapy in our sample were poor, with approximately 28% without any fills for controller therapy in the previous year, although patients with at least 1 prescription fill for combination controller therapy were more than twice as likely to have had a prior ICU admission. We previously reported that higher controller medication fills in our study population were found in patients with specialty care10,26; however, the low percentage of children with previous ICU admissions who had seen a specialist in the past 2 years is concerning (<20%). The NAEPP guidelines recommend consideration of referral to an asthma specialist for children with uncontrolled asthma,9 and in this particular high-risk group it should be strongly considered.
Barriers to medication adherence in asthma: The importance of culture and context
2018, Annals of Allergy, Asthma and ImmunologyCitation Excerpt :There is consistent evidence that adherence to controller medications across each of these steps is suboptimal. Many patients do not initiate controller medications when prescribed,10,11 fill medications only once after an initial prescription (eg, see Rust et al12 and Bender et al13), or discontinue controller medications prematurely, despite risk of exacerbation.14 When medications have been prescribed and filled, electronic monitoring of medication use consistently yields adherence rates of less than 70% of prescribed doses and often lower, in some reports ~60% for adult patients (eg, see Apter et al15), ~50% among pediatric patients (eg, see Morton et al16), and even lower among some populations, such as low-income adolescents (eg, 33%–41%17).
Factors associated with high short-acting β<inf>2</inf>-agonist use in urban children with asthma
2015, Annals of Allergy, Asthma and ImmunologyCitation Excerpt :Caregiver definition of well-controlled asthma might be based on the availability and response to SABA rather than recognition of symptom severity. Tolerance to SABA medication can be reversed with ICSs, yet low ICS adherence is known to exist in minority inner-city populations as reported in the present results.4,5,11,39 The lack of association between SHS exposure and high SABA use was surprising but consistent with a prior report of a comparable sample of inner-city children.10
Breathing easier: Addressing the challenges of aerosolizing medications to infants and preschoolers
2014, Respiratory MedicineCitation Excerpt :Poor understanding of the need for the drug may lead to poor compliance despite physician recommendations. A single center study of underserved children with asthma who received prescriptions for a controller medication by a specialist revealed that only 50% of ICS or ICS/LABA prescriptions were ever filled during an 18 month period, and the mean time to initial fill was 30 days from the date of the prescription [37]. Despite this, SABAs continued to be filled, likely reflecting an underlying lack of understanding of the importance of a maintenance therapy.
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.