Perceived caregiver financial barriers and asthma outcomes in urban elementary school children

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Perceived caregiver financial barriers and asthma outcomes in urban elementary school children

Minal R. Patel, MPH
Doctoral Student
Department of Health Behavior & Health Education
University of Michigan School of Public Health

American Thoracic Society International Conference , New Orleans, Louisiana
May 15, 2010

Center for Managing Chronic Disease
University of Michigan

Published in: Education, Health & Medicine
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  • Good afternoon. My name is Minal Patel. I am with the University of Michigan School of Public Health, and affiliated with the University of Michigan Center for Managing Chronic Disease. Today, I’ll be talking about a study which explored the association between perceived caregiver financial barriers and asthma outcomes in urban elementary school children.
  • The co-authors and I have no conflicts of interests or disclosures to report.
  • Asthma continues to be one of the most prevalent pediatric chronic illnesses, affecting 5.1 million children. Low-income and minority groups are disproportionately impacted by asthma, with African American and Latino children who live in low-socioeconomic urban environments experiencing higher rates of asthma morbidity and mortality. In a study of asthma-related hospital readmissions in children, they were found to be higher among residents from neighborhoods with higher levels of poverty. Persistent asthma severity has also been shown to increase the likelihood of emergency department re-visits and more missed school days in children.
  • Individuals with chronic illness often face financial pressures due to use of required or prescribed medications and medical equipment and/or frequent health care visits. Among adults with chronic illnesses, high out-of-pocket expenses have been shown to lead to medication underuse and higher utilization of costly forms of acute care such as ED visits and hospital stays. Although several studies have shown associations between concrete measures of socioeconomic status and asthma outcomes, it is not clear whether caregiver perceptions of their financial situation demonstrates the same relationship. While it is not always possible to assess all factors that contribute to a family’s financial situation in a clinical encounter, a better understanding of caregiver perceptions in this area may provide a unique opportunity for clinicians to promote more effective and less costly asthma management.
  • The purpose of this study was to describe the association of health outcomes and the perception of financial barriers among children with asthma. We hypothesized that asthma outcomes would be worse for caregivers who perceive financial barriers to obtaining care for their child’s asthma and children of parents with these perceptions subsequently would use more acute care services.
  • Data came from the baseline, caregiver interviews of the Partnership to Control Asthma in Public Schools intervention. This was a randomized control trial of an asthma education program aimed at children in 14 urban elementary schools in Detroit, Michigan. The study protocol was approved by the University of Michigan Institutional Review Board and the Detroit Public Schools system. In the baseline caregiver interviews, we asked about demographic and household characteristics; daytime and nighttime symptoms over the past 3 months to assess asthma control; insurance status; ED use, hospital stays, and missed school days over the past 12 months. To assess perceived financial barriers, we asked caregivers if their child’s asthma caused any financial problems for the family.
  • We initially approached 6,351 parents of all children in grades 2 to 5. They were provided a survey form designed to identify asthma cases. 4,576 parents returned the survey with sufficient data for analysis, of which 1,217 children were identified for participation in the randomized trial. Study inclusion criteria included either a physician’s diagnosis of asthma and active symptoms; no physician’s diagnosis, but reported presence of three or more of seven asthma symptoms in the past year; or report of either two exercise-related asthma symptoms with frequency of three times or more, in the past year. Exclusion into the study was based on not meeting these aforementioned criteria. Of 1,217 children fitting these initial case identification criteria, parents or caretakers of 835 children agreed to participate and provided baseline data. Reasons for not participating were primarily that the family moved, could not be contacted after several attempts, or believed the child did not have asthma.
  • In our analysis, we ran simple frequencies and descriptive statistics for our child and household characteristics and chi-square and multivariate logistical regression analyses to look at associations between asthma outcomes and perceived financial barriers. Significance was determined at p values less than 0.05.
  • The mean age of children in the sample was 8.4 years. 53% of children were male and 94% were African American. 43% of children had quick reliever medication while 16% were on a daily controller medication. 69% of our sample had well controlled asthma, while 31% had not well or poorly controlled asthma. 80% of the children in this sample also had mild intermittent asthma.
  • 9% of caregivers in this sample perceived financial barriers in obtaining asthma care for their child. At the time of data collection, 10% of children were covered under Medicaid, while 80% were not covered by any insurance. 82% of households had an annual household income below $40,000, and 75% of heads of households were mothers to the children.
  • Differences in perceptions of financial barriers by caregivers and child and household factors were examined. There were significant differences between caregivers who reported perceived financial barriers due to their child’s asthma and those who did not with regards to annual household income and asthma control, however no differences by insurance status were found. Those perceiving barriers were likely to be of lower income and have a child whose asthma is not controlled.
  • We ran 3 separate multivariate logistic regression models. We controlled for annual household income, insurance status, and asthma control in the models. We found that caregivers who perceived financial barriers in obtaining asthma care for their child were more likely to have the child experience at least one ED visit, at least one hospitalization, and at least one missed school day due to asthma.
  • In our study, we found that the majority of caregivers did not perceived financial barriers in obtaining care of their child’s asthma. However, among caregivers who did, we found that their associations between poor outcomes for their children, and perceptions of financial barriers.
  • There are several limitations to this study that should be noted. African Americans have disproportionate prevalence of asthma and the sample was predominately African American. Therefore these findings may not be generalizable to other populations. Errors in caregiver recall may have affected the accuracy of the numbers reported. However, recall of signal health care events such as ED visits and hospital stays have been shown to correlate highly with medical records of such events. Finally, because they are rare events, only a small number of asthma related ED visits and hospital stays were evident in our sample. As a result, the findings for these outcomes should be interpreted with caution.
  • Notwithstanding these limitations, there are several important implications from the findings of this study for health care providers. Although the subset of parents who perceived barriers was small, the associated consequences in health care use and missed school days were significant in terms of disruption to family life and costs to the health care system. This group even if small deserves attention from clinicians. The cost of medications and health services may not be within the control of individual practitioners, however simple actions might be taken to reduce this concern for parents, especially low-income families. Health care providers can ask caregivers if they experience specific financial barriers in obtaining medicine and asthma devices and adjust their clinical recommendations accordingly, for example, prescribing generics or insurance covered medicines. They might inquire if the family has explored routine options for insurance coverage and provide information regarding access to these. They also might refer patients to local community organizations assisting those with health and economic concerns or pharmaceutical assistance programs. None of these are time consuming actions and may both assist some families and promote shared asthma-care decision-making and patient satisfaction.
  • I’d like to thank Drs Noreen Clark, Melissa Valerio, Michael Cabana, Janet Coffman, and colleagues at the Center for Managing Chronic Disease.
  • Perceived caregiver financial barriers and asthma outcomes in urban elementary school children

    1. 1. Minal R. Patel, MPH Doctoral Student Department of Health Behavior & Health Education University of Michigan School of Public Health Perceived caregiver financial barriers and asthma outcomes in urban elementary school children American Thoracic Society International Conference , New Orleans, Louisiana May 15, 2010
    2. 2. Disclosure Statement <ul><li>Authors have no conflicts of interests or disclosures to report </li></ul><ul><ul><li>Minal R. Patel, Melissa A. Valerio, Michael D. Cabana, Janet M. Coffman, Noreen M. Clark </li></ul></ul><ul><li>Study was supported by the National Institutes of Health, National Heart Lung Blood Institute (NIH: HR-56028 ) </li></ul>
    3. 3. Background <ul><li>Asthma affects 5.1 million children </li></ul><ul><li>(Centers for Disease Control ) </li></ul><ul><li>Higher hospital readmission rates, emergency department re-visits, & more missed school days </li></ul><ul><ul><li>Neighborhood level poverty (Liu & Pearlman; Halfon & Newacheck) </li></ul></ul><ul><ul><li>Persistent asthma severity (Moonie et al.; Walsh-Kelly et al.; Clark et al. 2004) </li></ul></ul>
    4. 4. Background <ul><li>Financial pressures & disease management </li></ul><ul><li>Out-of-pocket costs have been shown to lead to medication underuse and higher use of acute care. (Bender and Rand 2004; Wagner et al., 2008). </li></ul><ul><li>The potential impact of a caregiver’s perceptions about cost barriers to obtaining asthma care for their children is not well understood. </li></ul>
    5. 5. Research Question <ul><li>Is there an association between caregiver perception of financial barriers and health outcomes in their children? </li></ul>
    6. 6. Data Source <ul><li>Partnership to Control Asthma in Public Schools intervention (Clark et al. 2004) </li></ul><ul><ul><li>Design: Randomized controlled trial </li></ul></ul><ul><ul><li>Baseline caregiver interviews </li></ul></ul><ul><ul><ul><li>Demographic characteristics </li></ul></ul></ul><ul><ul><ul><li>Asthma control </li></ul></ul></ul><ul><ul><ul><li>Insurance status </li></ul></ul></ul><ul><ul><ul><li>Health care utilization </li></ul></ul></ul><ul><ul><ul><li>Missed school days </li></ul></ul></ul><ul><ul><ul><li>Perceived financial barriers </li></ul></ul></ul>
    7. 7. Study Participation Initially approached 6,351 Returned survey 4,576 Eligible to participate 1,217 Agreed to participate 835 <ul><li>Sample (N=835) </li></ul><ul><li>Caregivers of children with asthma in grades 2-5 </li></ul><ul><ul><li>Recruitment </li></ul></ul><ul><ul><li>Inclusion criteria </li></ul></ul>
    8. 8. Analysis <ul><li>Simple frequencies and descriptive statistics </li></ul><ul><li>Chi-square analysis </li></ul><ul><li>Multiple logistical regression analysis </li></ul>
    9. 9. Results- Child Characteristics Factor % Age (M, SD) 8.40 (1.29) Sex (% male) 53% African American 94% Asthma medication use Reliever 43% Controller 16% Asthma Control Well controlled 69% Not well/poorly controlled 31%
    10. 10. Results- Household Characteristics Factor % Perceived financial barriers (% yes) 9%, (79) Medicaid 10% No Insurance (reported at BL) 80% Income below $40,000 82% Head of household (% mother) 75%
    11. 11. Results- Associations between perceived financial barriers, household, and child’s asthma characteristics Factor Perceived financial barriers due to asthma N (%) P-value Yes No Annual household income <0.01 <$20,000 58 (76%) 395 (57%) $20,001 - $40,000 13 (17%) 172 (25%) $40,001 - $60,000 4 (5%) 87 (12%) >$60,001 1 (2%) 44 (6%) Insurance Status NS Private (% yes) 8 (57%) 74 (47%) Medicaid (% yes) 5 (36%) 81 (52%) No insurance 65 (82%) 599 (79%) Asthma control <0.0001 Well controlled 31 (39%) 548 (73%) Not well controlled 26 (33%) 105 (14%) Poorly controlled 22 (28%) 102 (13%)
    12. 12. Results- Multivariate Model Significant Association <0.05* ; <0.01** Variable Multivariate OR [95% CI] Emergency department visits Hospitalizations Missed school days Perceived financial barriers (Yes) 2.17 [1.30 to 3.60]** 4.63 [2.40 to 8.92]** 3.76 [1.86 to 7.60]**
    13. 13. Summary of Findings <ul><li>The majority of caregivers did not perceive financial barriers in obtaining care for their child’s asthma </li></ul><ul><li>Parents of lower income and/or with a child whose asthma is not controlled may be more likely to see barriers to receiving care despite insurance status. </li></ul><ul><li>Poor outcomes for children were associated with parents’ perceptions of financial barriers to obtaining asthma care. </li></ul>
    14. 14. Limitations <ul><li>Population predominately African American </li></ul><ul><li>Self-report- recall (Cabana et al. 2006; Martin et al., 2000) </li></ul><ul><li>Small number of asthma-related acute care events </li></ul>
    15. 15. Implications <ul><li>Caregiver perceptions have consequences on outcomes </li></ul><ul><li>Health care providers can ask caregivers if they perceive specific financial barriers in obtaining medicine and asthma devices </li></ul><ul><ul><li>Adjust their clinical recommendations </li></ul></ul><ul><ul><li>Prescribe generics or insurance-covered medicines </li></ul></ul><ul><ul><li>Refer patients to local community organizations or pharmaceutical assistance programs </li></ul></ul>
    16. 16. Acknowledgments <ul><li>Thank you to: </li></ul><ul><ul><li>Noreen M. Clark, PhD </li></ul></ul><ul><ul><li>Melissa A. Valerio, PhD, MPH </li></ul></ul><ul><ul><li>Michael D.Cabana, MD, MPH </li></ul></ul><ul><ul><li>Janet M. Coffman, PhD, MPP </li></ul></ul><ul><ul><li>Colleagues at the Center for Managing Chronic Disease </li></ul></ul>

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