1. Accessibility to Inhaled Cortico-steroids among Adults with Chronic Asthma: AN IMPACT OF THE UNIVERSAL HEALTH CARE COVERAGE POLICY Chulaporn Limwattananon, MPharm, MSc, PhD * Supon Limwattananon, MPHM, PhD * Supasit Pannarunothai, MD, PhD ** * Faculty of Pharmaceutical Sciences, Khon Kaen University ** Center for Health Equity Monitoring, Naresuan University - Thailand - Thailand

2. Introduction Asthma: a chronic illness in 5-9% of adults (Boonsawat et al., 2002) and 10-13% of children (Vichyanond et al., 1998) in Thailand ICS: the most effective controller for persistent asthma (NHLBI, 2002) Low rate of ICS use: 6.6% of adults w/ asthma, a 4-province survey in Thailand ) The 2002 UC policy: To improve an access to necessary care for the poor and the uninsured, rest of population

3. Before 2002 After 2001 LICUCLIC (Low-Income Card) no copayment required UCROP Uninsured, 30-Baht copayment per visit rest of population (ROP)ROPCSMBS (Civil Servant Med. Benefit)SSS (Social Security) UC policy Oct. 2001

4. SchemePayment mechanism CSMBS Fee for service (Civil Servant (Retrospective, open-end, cost-based) Medical Benefit Scheme) SSS Capitation (Social Security Scheme)(Prospective, close-end, risk-based) UC Capitation for outpatient visit (Universal Coverage) + DRG for high-cost inpatient care LIC (defunct since 2002) Global budget (Low- Income Card)+ DRG for high-cost inpatient care Major Health Insurance Schemes

5. Objectives To determine the propensity to receive ICS as related to major health insurance schemes of adults with chronic asthma, taking into account of variations in patient demographics and severity of asthma

6. Settings: 17 MOPH-provincial hospitals in 4 regions of Thailand (secondary and tertiary acute care) Sample: A panel of 6,176 adult cohorts, aged > 18 years, receiving antiasthmatics for 3 consecutive years (2000 - 2002) Study Population

7. Retrospective, secondary analysis of electronic databases of drug use and patient hospitalization Statistical analysis : Logistic regression model * Effect of the UC policy on UC recipients was captured by the interaction between year of drug use and insurance scheme : Year2002 x UCLIC Year2002 x UCROP * Control for the underlying differences in propensity of ICS use due to Patient demographics (age, gender) Prior hospitalization and use of rescue medicine due to asthma (proxy for severity of asthma) Hospital settings (proxy for prescribing practice styles) Study Design & Analysis

8. Inhaled cortico-steroids (ICS): beclomethasone, budesonide, budesonide plus formoterol, fluticasone, fluticasone plus salmeterol Inhaled bronchodilators (BD-INH): formoterol, ipratropium plus fenoterol, ipratropium plus salbutamol, procaterol, salbutamol, salmeterol, terbutaline Oral bronchodilators (BD): aminophylline/theophylline, bambuterol, procaterol, salbutamol, terbutaline The Study Antiasthmatics

9. CSMBS UCLIC UCROP ROP SSS (N = 1,668) (N = 2,553) (N = 866) (N = 465)(N = 624) Fiscal year 2001 Inhaled corticosteroids 40.5% 25.3% 47.7% 34.4% 39.4% Bronchodilators only - Inhaled 3.7% 1.8% 3.0% 4.9% 5.6% - Oral 25.1% 25.7% 13.7% 21.9% 13.5% - Inhaled and oral 30.8% 47.2% 35.6% 38.7% 41.5% Fiscal year 2002 Inhaled corticosteroids 41.2% 25.0% 50.0% 27.1% 39.3% Bronchodilators only - Inhaled 4.7% 2.6% 1.6% 9.5% 7.7% - Oral 25.6% 26.3% 11.8% 27.1% 12.7% - Inhaled and oral 28.5% 46.0% 36.6% 36.3% 40.4% Recipients of Anti-asthmatics

10. ICS Non-ICS P-value recipients recipients Fiscal year 2001 (N = 2,139) (N = 4,037) Age 18 – 35 years18.3%11.1%< 0.001 Age 36 – 49 years31.4%17.9% Age 50 + years50.3%71.0% Male43.6%52.5%< 0.001 Prior hospitalization14.2% 4.6%< 0.001 Prior use of 28.8%22.2%< 0.001 nebulizing beta-2 agonists Baseline Characteristics of Asthma Patients

11. ICS Non-ICS P-value recipients recipients Fiscal year 2002 (N = 2,130) (N = 4,046) Age 18 – 35 years17.6%11.5%< 0.001 Age 36 – 49 years30.8%18.2% Age 50 + years51.6%70.3% Male44.3%52.1%< 0.001 Prior hospitalization12.8% 4.4%< 0.001 Prior use of 33.4%24.7%< 0.001 nebulizing beta-2 agonists Baseline Characteristics of Asthma Patients

12. CSMBS UCLIC UCROP ROP SSS (N = 1,668) (N = 2,553) (N = 866) (N = 465) (N = 624) Hospitalization in 2000 No admission92.8% 93.3% 88.3% 92.0% 90.5% One admission 5.0% 4.4% 7.4% 5.6% 6.7% More than once 2.2% 2.3% 4.3% 2.4% 2.7% Median LOS 4 days 2 days 2 days 2 days2 days Hospitalization in 2001 No admission93.4% 93.9% 88.9% 93.8%90.5% One admission 4.6% 4.2% 8.2% 3.9% 6.4% More than once 2.0% 1.8% 2.9% 2.4% 3.0% Median LOS 4 days 2.5 days 2 days 2 days3 days Prior Use of Hospital Care for Asthma

13. Model with interaction terms Main effect model Coefficient a P value Age 36 – 49 years b 0.007 0.916 0.007 0.915 Age 50+ years b - 0.825 < 0.001 - 0.824< 0.001 Male - 0.112 0.009 - 0.112 0.009 Prior hospitalization 1.098 < 0.001 1.099< 0.001 Prior use of 0.523 < 0.001 0.521< 0.001 nebulizing beta-2 agonists CSMBS c 0.413 < 0.001 0.415< 0.001 UCLIC c - 0.136 0.206 - 0.175 0.027 UCROP c 0.351 0.003 0.385< 0.001 ROP c 0.133 0.355 - 0.070 0.501 Year 2002 - 0.229 0.242 - 0.249 0.093 CSMBS x Year 2002 0.004 0.979 UCLIC x Year 2002 - 0.080 0.591 UCROP x Year 2002 0.067 0.695 ROP x Year 2002- 0.422 0.042 a Based on logistic regression analysis, adjusted for hospital indicators b Age of 18-35 years as the reference category c SSS as the reference category Propensity to Receive ICS (Competing Models) Statistical non-significance

14. Odds ratio a P value 95% CI Age 36 – 49 years b 1.01 0.915 0.88 – 1.15 Age 50+ years b 0.44 < 0.001 0.39 – 0.50 Male0.89 0.009 0.82 – 0.97 Prior hospitalization3.00 < 0.001 2.57 - 3.50 Prior use of 1.68 < 0.001 1.52 - 1.86 nebulizing beta-2 agonists CSMBS c 1.51 < 0.001 1.29 - 1.77 UCLIC c 0.84 0.026 0.72 - 0.98 UCROP c 1.47 < 0.001 1.24 - 1.73 ROP c 0.93 0.492 0.76 - 1.14 a Based on logistic regression analysis, adjusted for years of drug use and hospital indicators b Age of 18-35 years as the reference category c SSS as the reference category Propensity to Receive ICS (Final Model)

15. 20012002 Risk Propensity to Receive ICS No prior hospitalization nor prior rescue medication With prior hospitalization and prior rescue medication CSMB UCROP SSS ROP UCLIC Year

16. Need for ICS was not met in certain groups of chronic asthma. UC policy in 2002 did not improve ICS accessibility for UC recipients who in 2001 had been covered by LIC (i.e., the UCLIC group). Patients covered by a generous scheme like CSMB were better off in an access to ICS. The facts that the propensity to receive ICS in the UCROP group was comparable to CSMB but far better than the UCLIC counterpart are worth to be further examined. Conclusion