Accessibility to Inhaled Corticosteroids among Adults with Chronic

Accessibility to Inhaled Cortico-steroids among Adults with Chronic Asthma: AN IMPACT OF THE UNIVERSAL HEALTH CARE COVERAGE POLICY Chulaporn Limwattananon, MPharm, MSc, Ph. D * Supon Limwattananon, MPHM, Ph. D * Supasit Pannarunothai, MD, Ph. D ** * Faculty of Pharmaceutical Sciences, Khon Kaen University ** Center for Health Equity Monitoring, Naresuan University - Thailand

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 Thailan • The 2002 UC policy: To improve an access to necessary care for the poor and the uninsured, rest of population

LIC )Low-Income Card) Oct. 2001 UC policy Before 2002 Uninsured, rest of population After 2001 UCLIC no copayment required UCROP 30 -Baht copayment per visit )ROP) ROP CSMBS )Civil Servant Med. Benefit( SSS )Social Security( SSS

Major Health Insurance Schemes Scheme Payment mechanism CSMBS Fee for service )Civil Servant Medical Benefit Scheme( (Retrospective, open-end, cost-based( 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 +DRG for high-cost inpatient care )Low- Income Card)

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

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 < 18 years, receiving antiasthmatics for 3 consecutive years (2000 - 2002)

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 : Year 2002 x UCLIC Year 2002 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)

The Study Antiasthmatics Inhaled cortico-steroids (ICS): beclomethasone, budesonide plus formoterol, fluticasone plus salmeterol Inhaled bronchodilators (BD-INH): formoterol, ipratropium plus fenoterol, ipratropium plus salbutamo procaterol, salbutamol, salmeterol, terbutaline Oral bronchodilators (BD): aminophylline/theophylline, bambuterol, procaterol, salbutamol, terbutaline

Recipients of Anti-asthmatics CSMBS UCLIC UCROP SSS (N = 866) (N = 465) (N = 624) (N = 1, 668) (N = 2, 553) 40. 5% 25. 3% 47. 7% 34. 4% 39. 4% 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% 41. 2% 25. 0% 50. 0% 27. 1% 39. 3% 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% Fiscal year 2001 Inhaled corticosteroids Bronchodilators only - Inhaled Fiscal year 2002 Inhaled corticosteroids Bronchodilators only - Inhaled

Baseline Characteristics of Asthma Patients ICS recipients Fiscal year 2001 (N = 2, 139) Non-ICS recipients P-value (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 nebulizing beta-2 agonists 28. 8% 22. 2% < 0. 001

Baseline Characteristics of Asthma Patients ICS recipients Fiscal year 2002 (N = 2, 130) Non-ICS recipients P-value (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 nebulizing beta-2 agonists 33. 4% 24. 7% < 0. 001

Prior Use of Hospital Care for Asthma CSMBS UCLIC UCROP (N = 1, 668) SSS (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% 2 days 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% 2. 5 days 2 days Median LOS 4 days Hospitalization in 2001 No admission Median LOS 4 days 2 days 3 days

Propensity to Receive ICS (Competing Models( Model with interaction terms Coefficienta P value Main effect model Coefficienta P value Age 36 – 49 years b Age 50+ years b 0. 007 - 0. 825 0. 916 < 0. 001 0. 007 - 0. 824 0. 915 < 0. 001 Male - 0. 112 0. 009 Prior hospitalization 1. 098 < 0. 001 1. 099 < 0. 001 Prior use of nebulizing beta-2 agonists 0. 523 < 0. 001 0. 521 < 0. 001 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 - 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 - 0. 422 0. 042 Year 2002 ROP x Year 2002 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

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 nebulizing beta-2 agonists 1. 68 < 0. 001 1. 52 - 1. 86 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

Risk Propensity to Receive ICS CSMB UCROP SSS ROP UCLIC No prior hospitalization nor prior rescue medication With prior hospitalization and prior rescue medication CSMB UCROP SSS ROP UCLIC 20022001 Year

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.