Original articles

Prevalence and treatment of asthma in the Michigan Medicaid patient population younger than 45 years, 1980-1986

B. Burt Gerstman, DVM, MPH, PhD, Lynn A. Bosco, MD, MPH, Dianne K. Tomita, MPH, Thomas P. Gross, MD, MPH, and Michelle M. Shaw, PharmD Rockville, Md., and Arlington, Va.

The prevalence and outpatient treatment of asthma were studied in the Michigan Medicaid patient population by use of computerized physician, hospital, and pharmacy reimbursement data to mark and track asthma-related medical transactions. Asthma cases were defined as patients with evidence of at least two diagnoses and prescription drug transactions consistent with asthma. More than 52,000 cases were thus ident$ed. The period prevalence of asthma was estimated on a year-by-year basis. The prevalence of asthma in the population increased from 2 .O per ,!OO Medicaid patients in 1980 to 2.8 per 100 Medicaid patients in 1986. Prevalence decreased with age until the age of 20 years and increased thereafter, and was higher in male children than in female children. In contrast, asthma was more prevalent in female adults than in male adults. Prevalence was higher in black subjects than in other races and higher in urban residents than in rural residents. The total number of reimbursements for antiasthma medications increased from 60,000 per year to 120,000 per year, and the average number of antiasthma prescriptions per Michigan Medicaid asthma case increased at the rate of 6.6% per year during the study interval. Changes in the preferred types of asthma treatment consistent with changes that have occurred in the general population were observed. These data suggest that the (relative and absolute occurrence of asthma and asthma treatment in the Michigan Medicaid population is increasing. (J ALLERGY CLINIMMUNOL 1989;83:1032-9.)

Asthma is a leading cause of morbidity affecting >8.5 million people in the United States.‘. ’ It is one of the most common chronic diseases of childhood and is a leading cause of disability in subjects younger than the age of 17 years. 24 Despite introduction of new drugs and new drug formulations for the treatment of asthma, asthma morbidity and mortality have not declined either in the United States or abroad.7-‘2 This fact has raised concern about current asthma- management practices. 1246

From the Food and Drng Administration, Office of Epidemiology and Biostatistics, Rockville, Md., and Health Information De- signs, Inc., Arlington, Va.

The views expressed in this manuscript are those of the authors and do not necessarily reflect the opinion or policy of the Food and Drug Administration.

Received for publication May 19, 1988. Revised Oct. 24, 1988. Accepted for publication Nov. 8, 1988. Reprint requests: B. Gerstman, DVM, MPH, PhD, Office of Ep-

idemiology and Biostatistics, Food and Drug Administration, 5600 Fishers Lane, Room 15-42, Rockville, MD 20857.

1032

I I Abbreviations used COMPASS: Computerized On-line Medicaid Phar-

maceutical Analysis and Surveillance System

NPA: National prescription audit MDI: Metered-dose inhaler

I I

Information about treatment of asthma on a popu- lation basis is generally lacking. Previous studies have used data obtained from selected outpatient pharma- cies to determine trends and patterns of asthma treat- ment in the population. ‘3 “3 ‘K I7 These previous studies suggest that the number of dispensed prescriptions for antiasthma drugs has increased markedly since the late 1970s and that significant changes in the relative fre- quency in type of drug treatment and route of admin- istration have occurred. I53 I7 In these studies, however, it has not been possible to distinguish between use of bronchodilator drugs for the treatment of asthma and other respiratory conditions. It has also been impos-

VOLUME 83 NUMBER 6

Asthma in Michigan Medicaid 1033

TABLE I. Average yearly prevalence by age, sex, race, and resi’dence, 1980-1986

Age - (yr) Cases

Prevalence Prevalence by Overall by sex Prevalence by race residence

COMPASS Prevalence M F Black White Other Urban Rural

0 to 4 6,360 186,932 3.4 5 to 14 6,01;! 199,821 3.0

15 to 19 1,463 95,668 1.5 20 to 29 2,59ll 168,635 1.5 30to 44 3,550 116,724 3.0

oto 44 19,977 767,780 2.6

Prevalences are per 100 Michigan Medicaid recipients.

4.2 2.5 4.9 3.0 1.9 3.8 2.1 3.7 2.3 4.6 2.4 1.7 3.4 1.7 1.7 1.4 2.2 1.3 .9 1.7 1.0 1.0 1.7 2.3 1.4 .8 1.8 .7 1.6 3.5 4.3 2.8 1.6 3.5 1.7 3.1 2.3 3.8 2.3 1.5 2.9 1.5

sible to determine the number and type of subjects treated.

The present study reports trends and patterns in asthma diagnosis and treatment in the Michigan Med- icaid patient population for the interval 1980 through 1986. Prevalence and frequency of drug use are determined with two different drug classification schemes. Changes in patterns of drug use, number of patients with asthma, and number of antiasthma pre- scriptions per patient are described.

METHODS Data base

Data presented in this article are derived from COMPASS (Health Information Designs, Inc., Arlington, Va.). Briefly, COMPASS is a large computerized data base of Medicaid billing data that has been developed for the postmarketing surveillance of drugs. COMPASS data originate from a com- puterized claims-processing system designed for fiscal and administrative control of Medicaid programs. Data are or- ganized into patient records known as “profiles” in which Medicaid-reimbursed health care transactions are arranged according to the date service was provided. This permits construction of medical service histories over time and en- ables these data to be used for postmarketing drng surveil- lance.‘*. I9

Study population and operative definition of asthma

The study population was defined on a yearly basis and included Michigan Medicaid enrollees younger than 45 years that demonstrated at least one reimbursement for ser- vices in their COMPASS profile. The primary manner in which individuals in this age range become eligible for Medicaid benefits is: through the Aid to Families with De- pendent Children programs. It is therefore not surprising to find that the study population primarily consisted of children and women of childbearing age (Table I).

Our method of case ascertainment relied on physician and hospital billing codes suggestive of asthma diagnoses and treatments. To increase the accuracy of distinguishing

potential cases from noncases, we focused on those indi- viduals who had at least two diagnoses of asthma (Inter- national Classification of Disease, 9th revision, Clinical Modification code 493) and at least two pharmacy claims for drugs primarily used to treat asthma within their COMPASS history. With this case definition, a total of 52,231 Medicaid subjects with asthma were identified.

Monitoring disease and drug use To estimate the period prevalence of asthma, profiles of

the aforementioned individuals were scanned for diagnostic and drug transactions suggestive of clinically active asthma. Yearly prevalences for the interval 1980 through 1986 were determined by age, sex, race, and residence. For the purpose of this article, Metropolitan Statistical Area residents were considered to be “urban,” and non-Metropolitan Statistical Area residents were considered to be “mral.” Prevalence for each year is reported per 100 Medicaid benefit recipients.

Drug use prevalence was estimated as the proportion of subjects with active asthma reimbursed for drugs of predefined classes. The following drug classes were used: MDIs, nebulizer solutions, sodium cromolyn, sustained-release tbeophyllines, immediate-release tbeoph- yllines, fixed-combination products, oral sympathomimetic drugs, systemic corticosteroids, and inhaled corticosteroids. Drug-use prevalence for each year is reported per 100 asthma cases.

In addition, drugs were classified according to their pri- mary pharmaceutical mode of action, ignoring route of ad- ministration and formulation type. The following mode of action classes were used: xanthines, which included sustained-release theophyllines, immediate-release theoph- yllines, and fixed-combination products with at least one theophylline constituent; adrenergic drugs, which included MDIs, nebulizer solutions, oral sympathomimetic drugs, and those fixed-combination products with adrenergic com- ponents; and anti-inflammatory drugs, which included sys- temic corticosteroids, inhaled corticosteroids, and sodium cromolyn. Note that fixed-combination products are double counted as both xanthines and adrenergic drugs according to this scheme.

The total and average number of Medicaid reimburse-

1034 Gerstman et al. J. ALLERGY CLIN. IMMUNOL. JUNE 1999

01 ! I I / I I I ,

O-4 5-9 lo-14 15-19 20-24 25-29 30-34 35-39 40-44

Age

Males Females -----______

FIG. 1. Average annual prevalence of asthma in subjects younger than 45 years in the Michigan Medicaid population by age and sex for the period 1980-1986.

TABLE II. Number of asthma cases, individuals in the COMPASS system, and prevalence from birth to 44 years, 1980-1986

Year Cases COMPASS Prevalence

1980 14,698 751,231 2.0 1981 17,747 809,467 2.2 1982 20,024 780,140 2.6 1983 22,641 833,317 2.7 1984 23,333 783,308 3.0 1985 21,35’7 707,916 3.0 1986 20,036 709,087 2.8

ments for antiasthma drugs used by cases was determined. Average rates of change per year were calculated by the following formula:

(x,.hoY’” - 1

where %., denotes either the prevalence or number of events observed during the rP interval in question and xc,,) denotes the prevalence or number of events during the first interval in question.” Although this formula may falsely assume a constant rate of change, it can, nonetheless, be useful in providing a summary statistic for the purpose of describing trends.

RESULTS Prevalence of asthma

Average annual prevalences by age, sex, race, and residence status are listed in Table I. The prevalence

of asthma reaches its minimum at age 20 years. The prevalence of asthma was higher in male subjects younger than 20 years than in female subjects of com- parable age, but was higher in female subjects older than 20 years than in male subjects of comparable age (Fig. 1). The overall prevalence was higher in black subjects than in white subjects and other races (3.8 versus 2.3 versus 1 S, respectively), and was higher in urban dwellers than in rural dwellers (2.9 versus 1.5, respectively).

Table II contains the number of cases, Michigan Medicaid benefit recipients in the COMPASS system, and prevalence of asthma from birth to 44 years for each of the 7 years of the study. During this interval, the prevalence increased from 2.0 to 2.8 per 100 Michigan Medicaid benefit recipients per year. This represents a 40% increase during 7 years of obser- vation.

Prevalence of drug use

Table III contains drug use prevalence estimates by age. Overall, use of sustained-release theophylline in- creased at an average rate of 17% per year. A con- comitant drop in the use of immediate-release the- ophylline occurred in all ages except from birth to 4 years in which use of this class of drug re- mained relatively constant. The prevalence of fixed- combination product use decreased dramatically over time, averaging a 22.3% decline per year. The use of

VOLUME 83 NUMBER 6

Asthma in Michigan Medicaid 1035

TABLE III. Prevalence of drug use per 100 patients with asthm.a by age, 1980 and 1986

0 to 4 5 to 9 10to14 15 to 19 20 to 29 30 to 44

Age group (VI 1980 1988 1980 1988 1980 1988 1980 1988 1980 1988 1980 I!388

Drugs used Sustained-release

theophylline Immediate-

release the- ophylline

Fixed- combination

Oral sympatho- mimetic

MDIs Nebulizer

solutions Sodium

cromolyn Inhaled cortico-

steroids Systemic corti-

costeroids

7 48 23 55 31 60 25 59 24 59 25 63

37 39 27 20 26 10 32 8 39 10 39 11

56 5 51 7 43 8 35 10 35 10 39 16

17 49 20 38 22 29 25 19 27 24 30 27

0 2 3 19 9 47 16 56 19 56 21 52 1 9 1 8 1 6 1 3 1 4 3 6

0 6 3 8 5 7 3 3 2 3 3 3

0 0 3 4 6 7 5 7 7 8 9 11

4 8 7 10 11 13 16 19 22 25 24 30

oral sympathomimetic drugs remained constant in adults and adolescents, but demonstrated more than a doubling in patients younger than 10 years.

Overall, MD1 use increased at a rate of 22.3% per year. More than half the identified patients with asthma older than 15 years received at least one MD1 prescription in 1986. In addition, it was somewhat surprising to find that the prevalence of MD1 use in children 5 to 9 years increased from 3% in 1980 to 19% in 1986.

Nebulizer solutions, inhaled corticosteroids, and sodium cromolyn were used by relatively few subjects with asthma. Systemic corticosteroid use was age re- lated; 30-year-old patients were more than three times as likely to receive systemic steroids than subjects with asthma younger than 10 years. Overall, systemic steroid use among asthma patients increased modestly.

Number of prescriptions

Changes in the total and average number of an- tiasthma prescriptions per case are illustrated in Fig. 2. The total number of prescriptions doubled from just under 60,000 to nearly 120,000 per year (12.2% rate of increase per year). Simultaneously, the number of cases increased from 14,698 in 1980 to 20,036 in 1986 (Table II). Accordingly, the average number of pre- scriptions per patient increased from 4.07 in 1980 to 5.98 in 1986 (6.6% rate of increase per year).

There was a threefold increase in sustained-release

theophylline use, a twofold increase in oral sympa- thomimetic prescription use, and a sixfold increase in MD1 use (Fig. 3). There was nearly a twofold de- creased in fixed-combination product use and a slight decrease in immediate-release theophylline use. The number of reimbursements for nebulizer solutions, cromolyn sodium, systemic corticosteroids, and cor- ticosteroid inhalers increased slightly.

The number of Medicaid reimbursements and percent of market share by the aforementioned broad mode of action categories (see Methods sec- tion) are presented in Table IV. The number of reimbursements for xanthines peaked in 1984. There was a :steady increase in the number of adrenergic and anti-inflammatory drugs. Adrenergic and anti- inflammatory drugs steadily increased market share.

Comparison of Medicaid and NPA drug use estimates

Previously reported NPA drug-use estimates (IMS America, Ltd., Ambler, Pa.) are used for comparison with Medicaid data. Since NPA data do not assess drug treatment in relation to disease, comparisons are restricted to oral bronchodilator, inhaled bron- chodilator, and inhaled anti-inflammatory drug-use estimates.

NPA projections suggest that the use of the drug classes in question, irrespective of indication, in- creased from 37 million prescriptions in 1981 to 5 1

1036 Gerstman et al. J. ALLERGY CLIN. IMMUNOL. JUNE 1989

/ 5 98

4.79 5.06 5.2

4 07 4.25 11111 4 26

1980 1981 1382 1983 1954 1985 1986

Year

PrescrIptions per Case Total Prescrmpt~ons

FIG. 2. Total and average number of Medicaid reimbursement for antiasthma prescriptions among subjects with asthma 1980-1986.

TABLE IV. Reimbursed prescriptions and percent of market share within a given year (percent) by year and primary pharmacologic mode of action, 1980 through 1986

Year

1980 1981 1982 1983 1984 1985 1986

Xanthine Adrenergic Anti-inflam

n % n % n %

39,950 48.8 34,153 41.7 7,808 9.5 48,264 49.1 40,370 41.1 9,580 9.8 50,726 47.7 44,343 41.7 11,235 10.6 61,075 46.9 55,129 42.3 14,158 10.9 63,221 45.8 59,753 43.3 15,124 11.0 54,461 43.8 55,155 44.3 14,852 11.9 55,468 42.0 60,298 45.7 16,250 12.3

Anri-infim, anti-inflammatory. Fixed combination products are counted as both xanthines and adrenergic drugs.

million prescriptions in 1985.” This represents an 8.4 average annual rate of increase. During this same pe- riod, use of these drugs in the identified Medicaid population with asthma increased from 75 5 thousand prescriptions to 111.1 thousand prescriptions. This represents a 10.2% annual rate of increase.

Moreover, parallel changes in market share of the considered drug classes are observed (Fig. 4). For example, sustained-release theophylline formulations accounted for 22% of the total number of prescriptions of the considered drug classes in 1981 by both NPA and Medicaid estimates. By 1985, sustained-release

theophyllines increased to 38% and 36% of use in NPA and Medicaid estimates, respectively. Other drug classes shifted market share in consort, suggesting that trends in bronchodilator therapy in Medicaid subjects with asthma parallel that of the general population, indication of use notwithstanding.

DISCUSSION Prevalence of asthma

Comparisons of the asthma-prevalence estimates among various studies are difficult because of dissim- ilarities in case definitions and case-ascertainment

VOLUME 83 NUMBER 6

Asthma in Michigan Medicaid 1037

0 ‘I 980 1981 1982 1983 1984 1985 1986 Year

-s+SRTheo

- MDI

- POSym

-+ IRTheo

- FComb

+ sysst

+ NebSol -.+- Crom -4 InSt

FIG. 3. Number of reimbursements for sustained-release theophylline W?Theo), metered-dose inhalers (MD/), oral sympathomimetic drugs (POSym), immediate-release theophylline f/RTheo), systemic steroids (SysSt), nebulizer solutions (NebSol), cromolyn (Cram), fixed-combination products {FComb), and inhaler corticosteroids (/nSt), 1980-1986.

Percent Market Share, 1981 Percent Market Share, 1985 .-

36 36

30 30

26 26

20 20

16 16

10 10

6 6

0 0 SRTheo IRTheo FComb POwm MDI NabSol Cram blst SRTheo IRTheo FComb POwm MDI NebSol Croln

D&g Class Drug Class m Vational (NPA) @ Medicafd m National INPA) @ MedlCaid

FIG. 4. Comparison of national and Medicaid drug estimates. A comparison of percent distri- bution of outpatient prescriptions for a selected group of antiasthma drugs, NPA projections versus Michigan Medicaid asthma cases, 1981 and 1985.

methods.21.22 For example, nationwide (United States) estimates of asthma prevalence, as determined by the National Center for Health Statistics, are often derived by survey questionnaire. In contrast, our method of case ascertainment relied on billing codes from health care providers for asthma-related medical transac- tions. In our opinion, our method is likely to be less sensitive, but more specific, than questionnaire-

derived estimates. Therefore, it was not surprising to find that our prevalence estimates were lower than estimates of the National Center for Health Statistics for the United States as a whole.‘.“* 5

However, in spite of differences in methods and possible nonrepresentativeness of the population un- der study, several important patterns of disease are readily apparent. For example, decreasing prevalence

1038 Gerstman et al.

with age during late adolescence and early adulthood followed by increasing prevalence with age during the latter half of the third decade onward has been re- ported.‘, 3-5, 23 The higher prevalence in male children and adolescents compared to female children and ad- olescents has also been widely reported.” 23-28 In ad- dition, the higher prevalence in black subjects com- pared to white subjects is consistent with previously published studies. *, *’

We found a higher prevalence of asthma in urban residents than in rural residents, suggesting a disparity in either disease occurrence or health care practices. Note that no adjustment has been made for race in these analyses; therefore, the apparent urban excess may partially reflec:t the unequal distribution of race in the Medicaid population, with few black subjects in the rural Medicaid population.

Increases in asthma prevalence over time may re- flect actual increases in prevalence or trends in di- agnostic and treatment practices. In either event, in- creases in the number of Medicaid patients with asthma must be considered when drug use is inter- preted for estimates.

Drug use

Sustained-release theophylline and oral sympatho- mimetic drugs have replaced fixed-combination prod- ucts as the preferred treatment for asthma in children. Sustained-release theophylline and MDIs have re- placed immediate-release theophylline and fixed- combination products as the preferred treatment for asthma in adolescents and adults. In addition, a sig- nificant proportion of adults with asthma use systemic steroids during their course of therapy. Increasing use of oral sympathomimetic drugs in young children and use of MDIs in adolescents and adults has resulted in a general trend toward greater reliance on sympatho- mimetic drugs for asthma treatment (Table IV).

The average number of antiasthma drug reimburse- ment per Michigan Medicaid asthma case increased at the rate of 6.6% lper year during the study interval. This is more than three times the rate of overall Med- icaid drug reimburs’ement nationwide. (The U.S. De- partment of Health and Human Services reported a 2% annual growth of Medicaid drug reimbursements nationwide for the period 1973 through 1983.29) It therefore appears that the rise in antiasthma drug use is not simply an artifact of the reimbursement system. In summary, the relative and absolute occurrence of asthma and asthma treatment in the Michigan Medi- caid population appears to be increasing.

We express our graritude for the programming assistance of Ms. Dede Hill, and the epidemiologic advice of Dr. Frank Lundin, Dr. Carlene :Baum, and Dr. Joel Ku&sky.

J. ALLERGY CLIN. IMMUNOL. JUNE 1989

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Asthma in Michigan Medicaid 1039

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