Use of Inhaled Corticosteroids After Hospitalization for Asthma

Andrews AL, Bundy DG, Simpson KN, Teufel RJ 2nd, Harvey J, Simpson AN,. Inhaled corticosteroid claims and outpatient visits after hospitalization for asthma among commercially insured children. Acad Pediatr.  2017;17(2):212-217.

Asthma is one of the most common chronic pediatric conditions, and carries with it a significant burden of hospitalizations and emergency department visits. Recent evidence has shown that improved hospital-to-home transitions can increase adherence to inhaled corticosteroids (ICS), a treatment that both reduces symptoms and improves quality of life. One of the key ways to support families during this high-risk time after discharge is to encourage close outpatient follow up, continue educational efforts, and reinforce the role of controller medications in the management plan.

Prior studies have examined statewide populations of Medicaid-insured children hospitalized with an asthma exacerbation, showing that only 52% had a pharmacy claim for an ICS within 60 days and less than half attended an outpatient follow-up appointment. There are fewer data on commercially insured children, despite research showing that families of these children are more likely to identify a medical home and more likely to fill written prescriptions for asthma medications.

Dr Andrews and her colleagues examined rates of ICS claims and outpatient follow-up appointment attendance among a national sample of commercially insured children hospitalized with acute asthma exacerbation. They also examined possible predictors of ICS claims, with hopes to improve medication adherence. The study was completed through a retrospective cohort analysis using a national database of children aged 2-17 years who were hospitalized for asthma.

In total, data from 5471 children were examined. Less than half (41%) were found to have a claim for ICS, and 76% had an outpatient visit within 30 days following hospital discharge. In the multivariate analysis, children who were found to have an ICS claim prior to the hospitalization were more likely to have a claim after discharge. The most reliable predictor of an ICS claim within 30 days after discharge was attending an outpatient follow-up visit. When the ages of children were examined, those aged 2-6 years were most likely to attend an outpatient appointment. Patients who had an ICS claim prior to admission were also more likely to attend a follow-up appointment after hospital discharge.

Interestingly, the rates of an ICS claim (41% within 30 days, 46% within 60 days) noted in this study were even lower than the rates identified among a statewide Medicaid population (52% within 2 months). One of the possible reasons for this could be the copays or deductibles associated with inhaled corticosteroids, but this was not formally studied within the context of this paper. Other reasons include inadequate asthma education or low rates of prescribing.

It is certainly of note that children who followed up with their primary care providers after discharge were more likely to have a claim for an ICS. This supports consistent communication between the inpatient team and the primary care providers to continue family education and support adherence.

There are some limitations to this study. As this cohort study used administrative claims, there were no clinical data to correlate the records used. The data also did not allow a distinction between a failure to prescribe ICS or a rate of unfulfilled prescriptions. It also could not be determined if prescriptions were coming from the hospitalization or the follow-up visit. 

As providers guide families towards optimal care of patients with asthma, inpatient and outpatient providers alike must work together to create clear channels of communication. Reconnecting families with their medical homes after discharge will help with medication adherence and better continued care of childrens’ asthma.

Jessica Tomaszewski, MD, is an Assistant Clinical Professor of Pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania, and a hospitalist pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware. 

Charles A. Pohl, MD—Series Editor, is a Professor of Pediatrics, Senior Associate Dean of Student Affairs and Career Counseling, and Associate Provost for Student Affairs at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.