Children's Health

Use of health care services and costs of care are substantial for children with asthma-related illnesses

Asthma is the leading cause of chronic illness among children. Asthma-related deaths and illnesses have increased in recent years among young people with asthma, who miss school three times as often as other youngsters. The economic impact of the disease is substantial, with total U.S. expenditures in 1990 exceeding $6 billion. Costly emergency visits and hospitalizations for children with asthma usually reflect poor primary care of the disease, which allows it to get dangerously out of control.

A study supported by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00034) shows that children with asthma are three times as likely as other children to have coexisting problems, such as sinusitis or middle ear infections, which contribute to their significantly higher use of health care services and related costs. A second study by AHRQ researcher, Alexander N. Ortega, Ph.D., and colleagues suggests that insurance status alone is not sufficient to explain differences in health care use among children with asthma. Both studies are summarized here.

Grupp-Phelan, J., Lozano, P., and Fishman, P. (2001). "Health care utilization and cost in children with asthma and selected comorbidities." Journal of Asthma 38(4), pp. 363-373.

These researchers analyzed the records of a large health care group to measure the impact of asthma and specific upper respiratory problems on the use and cost of health care for 71,818 children enrolled in the group plan during 1992. They found that children with asthma were three times more likely than those without asthma to have coexisting problems (comorbidities) such as sinusitis, middle ear infections (otitis media), and allergic rhinitis (26 vs. 9 percent), and that these problems led to higher health care use and costs compared with children who did not have asthma.

For example, children who visited the doctor several times for otitis media, sinusitis, or allergic rhinitis were 1.8, 4, and 12 times more likely, respectively, to have a diagnosis of asthma in the same year. In general, children with either asthma or other comorbidities had higher rates of use and mean costs in outpatient, pharmacy, urgent care, and inpatient care than other children.

Children with asthma had a 47 percent probability of being in the highest total cost quintile, but that declined markedly to 29 percent after accounting for comorbidities, which tend to exacerbate asthma problems. Children who had both asthma and related illnesses incurred costs for urgent care that were 2.6 times higher than urgent-care costs for children in the general population ($208 vs. $79). Compared with the general population of children, mean total health care costs were 1.6 times higher for those with comorbid illnesses but no asthma, 1.6 times higher for those with asthma but no comorbidity, and 2.7 times higher for those with both asthma and comorbidity.

Ortega, A.N., Belanger, K.D., Paltiel, A.D., and others. (2001, October). "Use of health services by insurance status among children with asthma." Medical Care 39(10), pp. 1065-1074.

It is well known that Medicaid-insured children with asthma use the emergency department (ED) more frequently than children with other types of insurance. However, it is not clear if this is due to access to primary care, medication use, or other factors. These authors found that insurance status was independently associated with ED use regardless of frequency of primary care visits for asthma (which typically reduce the need for emergency care), medication use, or greater symptom severity. Insurance alone, however, did not account for all the differences in ED use, suggesting the possible influence of psychosocial or personal factors.

The investigators prospectively studied health care use and asthma symptoms over a 1-year period for 804 children with asthma who were recruited from seven New England hospitals. They conducted home interviews on monthly symptoms, health care visits, insurance status, sociodemographic characteristics, and asthma-related risk factors. They used other data to identify providers' characteristics. After adjustment for frequency of asthma-related primary care visits, primary provider practice type, use of asthma specialists, and patient age, sex, medication use, and symptoms, Medicaid children still used the ED almost twice as often for asthma care as privately insured children. Race/ethnicity did not substantially alter the relationship between insurance status and health care use.

These findings suggest that disproportionately less use of primary care and greater use of ED services for asthma care by Medicaid and minority children may be better explained by psychosocial and/or personal factors, such as attitudes and beliefs. It would be helpful to understand the degree to which ED use is viewed as a substitute for urgent primary care among Medicaid enrollees (perhaps convenience of access and operating hours for disadvantaged patients). The researchers suggest that future studies focus on patient-provider communication in primary care settings and other patient/parent factors, such as maternal knowledge, attitudes, and beliefs.

Reprints (AHRQ Publication No. 02-R013) are available from the AHRQ Publications Clearinghouse.

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