Accessibility to Inhaled Cortico-steroids among Adults with Chronic Asthma:

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. Abstracts Problem Statement: Inhaled corticosteroids (ICS) are considered the most effective controller for persistent asthma. Previous reports showed relatively low rates of ICS utilization. The Universal Health Care Coverage (UC) policy first implemented in fiscal year 2002 aims to improve access to necessary health care for the poor and uninsured population. Objectives: To determine the availability of ICS related to major health insurance schemes of adults with chronic asthma. Design: Retrospective analysis of electronic databases of hospital drug use and patient admission. Setting and Population: 6,176 adults >18 years, receiving antiasthmatics for 3 consecutive years in 17 hospitals in Thailand. Outcome Measures: % of patients receiving ICS, inhaled and oral bronchodilators; adjusted odds ratio (OR) for receiving ICS. Results: Use of ICS proportional to all antiasthmatic use was relatively consistent during 2001-2002 at approximately one-third. Such ICS rates varied across health insurance schemes. The lower-than-average rate (25.0-25.3%) was found in the group of UC patients who in 2001 were covered by the Low-Income Card Scheme (UCLIC). The above-average rates were in the UC patients who in 2001 were the rest of population (UCROP) outside the Low-Income Card Scheme (47.7-50.0%), and patients eligible to Civil Servant Medical Benefit Schem (CSMBS) (40.5-41.2%) and Social Security Scheme (SSS) (39.3-39.4%). The ICS recipients and non-recipients were different in prior use of asthma care. The ICS group had been hospitalized (12.8-14.2%) and used rescue medicines in nebulizer forms (28.8-33.4%) in a previous year more than its counterpart (4.4-4.6% and 24.7-22.2%, respectively). Regarding the insurance schemes, prior hospitalization was more frequent in the UCROP (11.1-11.7%) and SSS (9.5%) groups than in the CSMBS (6.6-7.2%) and UCLIC (6.1-6.7%) groups. Adjusted for the differences in prior health care experience and patient demographics, CSMBS and UCROP had a higher propensity to receive ICS than the reference SSS (OR=1.51 for CSMBS and OR=1.47 for UCROP, P<0.001). The UCLIC patients were 16% less likely to receive ICS than by SSS (OR=0.84, P=0.026). Conclusions: The need for ICS was not met in certain groups of adults with chronic asthma. Such a discriminating medical practice still existed despite asthma severity reflected by prior experience of asthma care use. The patients covered by a generous scheme like CSMB were better off in access to ICS. The fact that the propensity to receive ICS in the UCROP group was comparable to CSMB but far better than the UCLIC counterpart is worth further examination.

3. 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

4. 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

5. Study Design & Analysis • Retrospective, secondary analysis of electronic databases of drug use and patient hospitalization • Settings: 17 MOPH-provincial hospitals in 4 regions of Thailand • Sample: A panel of 6,176 adult cohorts, aged> 18 years, • receiving antiasthmatics for 3 consecutive years (2000 – 2002) • Statistical analysis: Logistic regression model • Effect of UC policy on UC recipients was captured by the interaction between year of drug use and insurance (Year2002 x UCLIC; Year2002 x UCROP) • * Control for the underlying differences in propensity of ICS use due to • Patient demographics (age groups, gender) • Prior hospitalization and use of rescue medicine due to asthma • (proxy for severity of asthma) • Hospital settings (proxy for prescribing practice styles)

6. Recipients of Anti-asthmatics CSMBSUCLICUCROPROPSSS (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%

7. 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% < 0.001 Age 36 – 49 years 31.4% 17.9% Age 50 + years 50.3% 71.0% Male 43.6% 52.5% < 0.001 Prior hospitalization 14.2% 4.6% < 0.001 Prior use of 28.8% 22.2% < 0.001 nebulizing beta-2 agonists

8. 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% < 0.001 Age 36 – 49 years 30.8% 18.2% Age 50 + years 51.6% 70.3% Male 44.3% 52.1% < 0.001 Prior hospitalization 12.8% 4.4% < 0.001 Prior use of 33.4% 24.7% < 0.001 nebulizing beta-2 agonists

9. Prior Use of Hospital Care for Asthma CSMBSUCLICUCROPROPSSS (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 admission5.0%4.4%7.4%5.6%6.7% More than once2.2%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

10. 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 < 0.001 - 0.824 < 0.001 Male - 0.112 0.009 - 0.112 0.009 Prior hospitalization 1.098 < 0.001 1.099 < 0.001 Prior use of 0.523 < 0.001 0.521 < 0.001 nebulizing beta-2 agonists CSMBS c 0.413 < 0.001 0.415 < 0.001 UCLIC c - 0.136 0.206 - 0.175 0.027 UCROP c 0.351 0.003 0.385 < 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

11. 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 < 0.001 0.39 – 0.50 Male 0.89 0.009 0.82 – 0.97 Prior hospitalization 3.00 < 0.001 2.57 - 3.50 Prior use of 1.68 < 0.001 1.52 - 1.86 nebulizing beta-2 agonists CSMBS c 1.51 < 0.001 1.29 - 1.77 UCLIC c 0.84 0.026 0.72 - 0.98 UCROP c 1.47 < 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

12. 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

13. 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.