Community pharmacies may be positioned for an increased role in population health. We sought to develop a population-level measure of asthma medication fills and assess its relationship to asthma-related utilization.
We conducted a retrospective, ecological study (2010–2012). Medication data from a chain of pharmacies (n = 27) within 1 county were used to calculate a Pharmacy-level Asthma Medication Ratio (Ph-AMR), defined as controller fills divided by controller plus rescue fills. Higher values are superior because they indicate more controller compared with rescue fills. The outcome was the asthma-related utilization rate among children in the same census tract as the pharmacy, calculated by dividing all emergency visits and hospitalizations by the number of children in that tract. Covariates, including ecological measures of poverty and access to care, were used in multivariable linear regression.
Overall, 35 467 medications were filled. The median Ph-AMR was 0.53 (range 0.38–0.66). The median utilization rate across included census tracts was 22.4 visits per 1000 child-years (range 1.3–60.9). Tracts with Ph-AMR <0.5 had significantly higher utilization rates than those with Ph-AMR ≥0.5 (26.1 vs 9.9; P = .001). For every 0.1 increase in Ph-AMR, utilization rates decreased by 9.5 (P = .03), after adjustment for underlying poverty and access. Seasonal variation in fills was evident, but pharmacies in high-utilizing tracts filled more rescue than controller medications at nearly every point during the study period.
Ph-AMR was independently associated with ecological childhood asthma morbidity. Pharmacies may be a community-based leverage point for improving population-level asthma control through targeted interventions.
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Beck AF, et al's article about the Pharmacy-level Asthma Medication Ratio (Ph-AMR) and it's impact on the ecological childhood morbidity due to asthma is very pertient in instituting pharmacy as one of the leverage points in ensuring adherence (1).
The investigators only included ages 2 to 18 years, which left out pediatric age group of less than 2 years; eventhough diagnosis of asthma in this age group is difficult and non conclusive, the prevelance of viral induced wheezing or reactive airway disease that predisposes to future asthma could be significant(2).
Also, the hospital based administrative data extracted may be not entirely reflective of accurate diagnosis. In a study that was done by electronic database showed that the asthma identification had a sensitivity of only 44.8% (3). In a study that examined the accuracy of hospital coding, it was shown that at least 1 coding change occurred in 51% patients. There were 13% and 12% changes to primary diagnoses and procedures, respectively(4). ICD9 code of asthma (493.00) can be primary or secondary , the asthma patients who presented to Cincinnati Childrens hospital may have presented for a non respiratory issues. Current hospital coding/billing practice is not entirely accurate in deciphering the diagnosis for which patients seek healthcare attention. Hence the above data from the hospital utilzation may be hyper inflated or under represented.
References
1.Andrew F. Beck, Courtney L. Bradley, Bin Huang, Jeffrey M. Simmons, Pamela C. Heaton, and Robert S. Kahn. The Pharmacy-Level Asthma Medication. Ratio and Population Health. Pediatrics 2015; 135:1009-1017
2.Stein RT. Long-term airway morbidity following viral LRTI in early infancy: recurrent wheezing or asthma? Paediatr Respir Rev. 2009 Jun;10 Suppl 1:29-31
3. Silfen E. Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record. Am J Emerg Med. 2006 Oct;24(6):664-78.
4. Nouraei SA, Hudovsky A, Frampton AE, Mufti U, White NB, Wathen CG, Sandhu GS, Darzi A. A Study of Clinical Coding Accuracy in Surgery: Implications for the Use of Administrative Big Data for Outcomes Management. Ann Surg. 2014 Dec 2
Conflict of Interest:
None declared