Asthma is the most common childhood chronic disease, yet millions of children go undiagnosed each year. A new study by RWJF Clinical Scholars confirms that a child without health insurance—who lacks regular screening that could detect even intermittent symptoms—is less likely to have a diagnosis than a child with coverage.
"It's not surprising that there is a reservoir of undiagnosed children," says lead author Tumaini R. Coker, MD, MBA, an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2004-2006). Coker is an assistant professor of pediatrics at the University of California, Los Angeles and an associate natural scientist at the RAND Corporation. Parents often do not recognize that their child's intermittent symptoms are part of a larger problem, or they get used to dealing with the symptoms and do not bring it up with their health care provider.
But, even children without persistent symptoms may benefit from being diagnosed and treated, she says.
With a large number of children expected to gain insurance coverage under the Children's Health Insurance Program Reauthorization Act and the increased coverage of parents under the health reform law, more kids will soon have access to treatment.
"We're likely going to see more children getting insurance," Coker says. "So for those children who have asthma symptoms but are not diagnosed, we wanted to see the relationship between insurance coverage, asthma diagnosis and asthma-related outcomes." That will have implications for children who get coverage in the future, she said.
Her study, coauthored by Clinical Scholars alumnus Paul J. Chung, MD, MS, and colleague Robert M. Kaplan, PhD, was published online on October 27, 2011 in the journal Health Services Research. It is part of a special issue on "Bridging the Gap Between Research and Health Policy" that features research articles from current and former RWJF Clinical Scholars. The print edition will be published in February 2012.
Using data on more than 11,000 children under the age of 18 from a population-based household survey conducted by the National Center for Health Statistics, the researchers found that among children with intermittent symptoms, insured children had four times greater odds of having an asthma diagnosis than uninsured children. Insured children with intermittent symptoms also had 4.5 times the odds of receiving long-term inhaled corticosteroid treatments for their asthma.
Health insurance played a much smaller role in asthma diagnosis among those with persistent symptoms, however. "Children with more persistent symptoms seemed more likely to get a diagnosis regardless of their [health insurance] status," Coker explains. They are more likely to seek treatment at clinics, urgent care centers and emergency departments regardless of their insurance coverage, presenting equal opportunities for diagnosis.
The study's findings suggest that increasing access to insurance could lead to the identification and diagnosis of more children with intermittent symptoms. "Having health insurance may lead to a diagnosis for children who otherwise may not have been diagnosed because they don't go to doctors' offices or emergency departments as often as those with more persistent symptoms," Coker says.
Diagnosis May Lead to Greater Care Utilization
While insured children with intermittent symptoms were more likely to be using corticosteroid treatments to control their symptoms than their counterparts without insurance, they were also more likely to have recently visited a doctor or the emergency department for an asthma attack. This finding among children with intermittent asthma symptoms could be because of parents' heightened sensitivity to symptoms after their child has received a diagnosis, the authors explain. These differences in asthma diagnosis, treatment and utilization by health insurance were not observed for those with persistent symptoms.
Uninsured children may have a similar need for acute care, but may be unable to receive it consistently because they do not have coverage.
The increase in insured children expected soon "may reduce the number of undiagnosed children with intermittent asthma symptoms and ensure that they receive more appropriate treatment," the authors write. "[L]arge cost savings from reduced care utilization, however, may not be a realistic expectation."
It is unclear whether expanding health insurance coverage could lead to societal benefits in terms of a reduction in utilization of emergency department and acute care, Coker says. She hopes that future research will expand on their findings. "We might find other long-term benefits and costs of detecting and treating those previously undiagnosed children with intermittent symptoms."
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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