Effect of Physician Asthma

Education on Health Care Utilization

of Children at Different Income
Levels

Randall Brown, Noreen Clark, Niko Kaciroti,

Molly Gong, Michael Cabana, Juanita Lyons
University of Michigan
Funded by NHLBI Grant #HL44976
May 2002
Background

This is a substudy of a randomly controlled

trial to assess patient outcomes resulting
from asthma care education for their
physicians.
The education was an interactive seminar
designed to enhance physicians’
therapeutic skills in treating children with
asthma and to develop their capacity to
educate and counsel families about asthma
self-management.
Purpose

The purpose of this substudy was to

examine program effect on hospital
admissions and emergency department
visits among children of different income
levels.
Methods

Data Collection
• Patients’ telephone interview:
• Data was collected at baseline, within a 22-
month window following the first visit to their
physician subsequent to the seminar, and 12
months thereafter.
Samples

Physicians Patients

Baseline 74 637

Follow-up 1 69 450
Male
Follow-up 2 66 369
 Physician Characteristics

Gender Age 60 and

older 30-39

Female 14% 27%

Male 40% 50-59

60% 27%
40-49
37%
Patient Characteristics Native American
1% Other
4%
Asian
2%

Gender Race/Ethnicity
Latino/Hispanic
Girls Girls 12%

30% 30%
African
Boys American
70% White
15% 66%
 Patient Characteristics

Household Parent Education

Income Level < High
School
> College
>C

> 80 K < 20 K 22%

14%
ol l
14

eg

19% 20%
%

High
High School
60-80 K School 3-4 years of College
20-40 K 27% 22%
19% 22%
22%
40-60 K 1-2 years College
27%
20%
Data Analysis

Technique
Models were derived from Poisson
regressions with generalized estimated
equation (GEE) analyses covering three
periods: baseline to 12-months, 12 to 24-
months, and baseline to 24 months.
Parameters

Previous response regarding the outcome

variables of interest and prior and current
inhaled anti-inflammatory medication use
were controlled in each model.
An interaction (program participation x
income, coded as levels 1 to 11 from low
to high mean = 7.1), and program
participation were included to examine if
the effect of the intervention differed
according to income level.
The Model

Number of ED/Hospitalizations at Follow-up 1 or

Follow-up 2
+ Baseline score or first Follow-up score
+ Program participation
+ Income
+ Inhaled medication use at Baseline
+ Inhaled medication use at Follow-up 1 or
Follow-up 2
+ Interaction term of program participation x
income
Results
Table 1. Adjusted Yearly Rate of Hospitalizations for
Families of Different Income Levels

Baseline to Follow-up 1 Follow-up 1 to Follow-up 2 Baseline to Follow-up 2

Income Treatment Control Treatment Control Treatment Control

< 20,000 0.025 0.049 0 0.098 0 0.080

N = 31 N =28 N = 17 N = 17 N = 17 N = 20

20,000 & plus 0.041 0.34 0.022 0.83 0.034 0.99

N = 195 N = 148 N = 136 N = 103 N = 140 N = 105

* Yearly rates were calculated using the following formulae:

Yearly rate = ek x 365
k = intercept + b1 x mean Baseline or Follow-up 1 score + b2 x program
participation + b3 x income + b4 x medication use + b5 x interaction of income
x program participation
Results
Table 2. Adjusted Yearly Rate of ED Visits for Families
of Different Income Levels

Baseline to Follow-up 1 Follow-up 1 to Follow-up 2 Baseline to Follow-up 2

Income Treatment Control Treatment Control Treatment Control

< 20,000 0.351 0.728 0.314 2.383 0.252 1.572

N = 31 N = 27 N = 17 N = 17 N = 17 N = 25

20,000 & plus 0.321 0.324 0.257 0.252 0.257 0.255

N = 195 N = 146 N = 136 N = 103 N = 136 N = 101

* Yearly rates were calculated using the following formulae:

Yearly rate = ek x 365
k = intercept + b1 x mean Baseline or Follow-up 1 score + b2 x program
participation + b3 x income + b4 x medication use + b5 x interaction of income
x program participation
Results
Table 3. Estimates and p-values for Program Participation and Interaction of
Program Participation and Income
Baseline to Follow-up 1

Parameter Treatment Treatment x income

Outcome Estimate p-value Estimate p-value

Hospitalizations 0.0182 0.9609 0.0357 0.6930

ED Visits - 0.1081 0.6533 0.1053 0.1269

* Regardless of family income, the effects of physician education on

health care utilization were not revealed from Baseline to Follow-up 1.
Results
Table 4. Estimates and p-values for Program Participation and Interaction of
Program Participation and Income
Follow-up 1 to Follow-up 2

Parameter Treatment Treatment x income

Outcome Estimate p-value Estimate p-value

Hospitalizations - 1.139 0.0634* 0.0862 0.6359

ED Visits - 0.1997 0.4994 0.3001 0.0029**

* Regardless of family income, children whose physicians were in the

intervention group had significantly fewer hospital admissions from
Follow-up 1 to Follow-up 2.
** The education for physicians was significantly effective in reducing
ED visits for lower income children from Follow-up 1 to Follow-up 2.
Results
Table 5. Estimates and p-values for Program Participation and Interaction of
Program Participation and Income
Baseline to Follow-up 2

Parameter Treatment Treatment x income

Outcome Estimate p-value Estimate p-value

Hospitalizations - 1.507 0.0169* 0.1707 0.3834

ED Visits - 0.2451 0.4457 0.3396 0.0123**

* Regardless of family income, children whose physicians were in the

intervention group showed a strong trend toward fewer hospital
admissions from Baseline to Follow-up 2.
** The education for physicians was effective in reducing ED visits at
lower income levels from Baseline to Follow-up 2.
Conclusions

1. The education interactive seminar for physicians

did not effect hospital admissions and ED visits from
Baseline to Follow-up 1.
2. Regardless of family income, the interactive
seminar for physicians reduced hospital admissions
from Follow-up 1 to Follow-up 2 and from Baseline
to Final Evaluation.
3. The program effect on ED visits from Follow-up 1
to Follow-up 2 was found only in children whose
family income was less than $20,000.