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(Chest. 2004;125:1359-1367.)
© 2004 American College of Chest Physicians

A Survey of Medicaid Recipients With Asthma*

Perceptions of Self-Management, Access, and Care

Joseph Anarella, MPH; Patrick Roohan, MS; Elizabeth Balistreri, PhD and Foster Gesten, MD

* From the Office of Managed Care (Mr. Anarell, Mr. Roohan and Dr. Gesten), New York State Department of Health, Albany, NY; and the Managed Care Department (Dr. Balistreri), Island Peer Review Organization, Lake Success, NY.

Correspondence to: Joseph Anarella, MPH, Assistant Director, Bureau of Quality Management and Outcomes Research, Office of Managed Care, New York State Department of Health, Corning Tower, Rm 1955, Empire State Plaza, Albany, NY 12237; e-mail: JPA02{at}health.state.ny.us


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix
 References
 
Study objectives: To understand how Medicaid recipients with asthma view their experience with care.

Design: Survey sent to Medicaid managed care enrollees.

Setting: A survey designed to assess general health status, access to care, medication-taking behaviors, and overall satisfaction was sent to 25,171 patients with moderate-to-severe asthma.

Results: A total of 92% of patients rated their asthma care as good or excellent, 64% of adults reported their health as fair or poor, while only 27% of children reported their health as being fair or poor. Respondents were well-educated regarding their asthma, with 87% reporting knowing what to do for severe asthma attacks, 78% knowing the early warning signs of an asthma attack, and 77% recognizing aggravating factors. Eighty-nine percent of respondents rated the quality of the information given to them by their provider as very good or good. While 75% of patients reported using inhaled steroids, only 38% of those reported using them on a daily basis. Forty percent of patients reported using inhaled steroids only when they have symptoms. Forty-six percent of adults either smoke cigarettes or are exposed to smoking in the home, while 35% of children are exposed to smoke in the home.

Conclusion: Asthmatic patients rated the quality of the information that their physicians provide very highly and reported that that they understand how to treat exacerbations. However, they do not take prescribed inhaled steroids on a daily basis. In addition, many asthmatic patients reside in homes where cigarette smoking is present.

Key Words: asthma • Medicaid managed care • survey


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix
 References
 
Asthma represents a particularly serious health issue for New York State Medicaid recipients who are enrolled in managed care. Medicaid managed care encounter data from 2001 revealed that asthma was the seventh most frequently occurring diagnosis among Medicaid managed care members. The New York State Department of Health (NYSDOH) estimates that approximately 26,000 of a total 800,000 Medicaid recipients enrolled in managed care plans may have moderate-to-severe asthma. Medicaid recipients with asthma who were enrolled in managed care in 2001 averaged 6 hospital admissions, 25 emergency department visits, and 177 primary care visits for asthma per 100 members (NYSDOH Medicaid encounter data).

The NYSDOH has monitored asthma care for Medicaid recipients enrolled in managed care by conducting two focused clinical studies using medical record review in 1997 and 2000 (NYSDOH unpublished medical review study). These studies identified a number of areas in which treatment was suboptimal, including the daily use of inhaled corticosteroids, patient education, the use of peak expiratory flow rate meters, the assessment of triggers, monitoring of theophylline levels, and coordination of hospital and ambulatory care. These results are consistent with findings that have been described in the literature123 across populations and are not limited to Medicaid managed care patients. However, there are limitations to the use of medical records for determining compliance with clinical standards. Medical record abstractions typically underreport care components such as patient education that are known to be poorly documented by clinicians.

The use of patient/enrollee surveys provides another data source. Patient/enrollee surveys of care have been extensively developed by organizations such as the Agency for Healthcare Research and Quality4 and the Foundation for Accountability (FACCT)5 as a means to assess care from a patient perspective. In the spring of 2001, the NYSDOH conducted a survey of Medicaid managed care recipients with asthma to evaluate their self-management behaviors, to measure their access to and satisfaction with care, and to assess asthma care as described by compliance with key components of the National Asthma Education and Prevention Program (NAEPP) guidelines. In this article, we present the findings from > 6,000 Medicaid recipients with asthma who were enrolled in managed care and responded to this survey.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 Appendix
 References
 
Two, virtually identical 29-question surveys were designed, one for adults with asthma and one for the parents of asthmatic children. The majority of the questions were obtained from the FACCT Adult Asthma Survey (version 2.0). Many of the FACCT survey questions were derived from other sources in the public domain, including the Behavioral Risk Factors Surveillance System6 and the Managed Health Care Association Study.7 Additional questions were developed by the NYSDOH to ensure that all key components of asthma care were assessed. The survey was written to be appropriate for a fifth grade reading level, and was available in English and Spanish.

Enrollees were asked to self-report on general health status and asthma severity. Key components of asthma care. including health assessments, medication use, exposure to tobacco smoke, patient education and comprehension, and ability to self-manage based on changes in symptoms or peak flow readings, were assessed. Additionally, enrollee access to providers, availability of asthma-related equipment, and overall satisfaction with asthma care was examined. The "Appendix" is a summary of the questions from the adult survey.

Asthmatic patients enrolled in Medicaid managed care were identified through the analysis of Medicaid encounter data. These data are submitted monthly by Medicaid plans, include records of all inpatient, outpatient, and laboratory encounters, and provide the NYSDOH with diagnosis and procedure code information. In addition, Medicaid claims are available for services that are not part of the managed care benefit, such as pharmacy services. To qualify for inclusion in the survey, Medicaid recipients had to be continuously enrolled in their health plan in the year 2000. They also had to meet at least one of the following criteria: one hospitalization with a primary diagnosis of asthma; two or more visits to the emergency department with a diagnosis of asthma; at least two outpatient visits with a diagnosis of asthma; or a minimum of five pharmacy prescriptions for an asthma medication within 24 months (as defined by the Health Plan Employer Data Information Set).

These criteria are a modified version of the "Use of Appropriate Medications for Persons With Asthma" measure criteria of the Health Plan Employer Data Information Set, which was changed in order to maximize the number of "true positives" and increase the number of individuals likely to have more than mild intermittent disease. Using this algorithm, surveys were sent to 25,171 asthmatic patients (10,461 adults and 14,710 parents of children aged 1 to 17 years) across 29 managed care plans. Parents with more than one child with asthma were requested to complete the survey for the oldest child.

The survey was conducted in a two-phase mailing. The initial mailing included a cover letter explaining the survey and a stamped return envelope. The second mailing to nonresponders occurred approximately 1 month later. In addition, a telephone survey of a random sample of nonresponders was conducted approximately 1 month after the second mailing to evaluate responder bias. A subset of six key questions from the survey was selected for use in the nonresponder telephone survey.

Socioeconomic and demographic variables used in this analysis included gender, age (ie, adult and child), and race/ethnicity (ie, white, black, Hispanic, and other). Family structure was measured by Medicaid aid category using the following three classifications: Temporary Assistance to Needy Families (TANF), which generally describes needy families that include a minor child deprived of parental support or care; Safety Net (SN), which generally describes individuals and childless couples; and Supplemental Security Income (SSI), which describes Medicaid that is made available to the aged, blind, or disabled. The region of the state was defined as New York City (NYC) and the rest of state.

{chi}2 tests were used to test for associations between age group and daily use of inhaled steroids, and survey and demographic variables. Logistic regression was performed to evaluate key determinates of daily inhaled steroid use. Univariate and multivariate analysis were conducted using a statistical software package (SAS for Windows; SAS Institute; Cary, NC).8


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 Appendix
 References
 
A total of 6,672 completed surveys were returned for a response rate of 28%. Of those surveys that were returned, 6,237 (94%) responded affirmatively to the initial screening question ("Has your doctor [or other health care provider] ever told you that you have asthma?"). All subsequent analyses were conducted on these 6,237 surveys.

In light of the low survey response, response bias analysis was performed. Response rates differed by Medicaid aid category and race/ethnicity. Members who had either SN or SSI assistance were more likely than members covered by TANF to respond to the survey (p < 0.001), with response rates of 32%, 33%, and 24%, respectively. White members were more likely to respond to the survey (30%), compared to black members (26%) and Hispanic members (25%; p < 0.001). To yield results more generalizable to the New York State Medicaid managed care asthmatic population, data were weighted by aid category and race/ethnicity to account for the differing response rates. Responses from members in subgroups with low response rates (eg, Hispanics with TANF) were weighted more heavily to better reflect their membership in the overall asthma population.

Demographic Characteristics
A total of 2,979 (94%) respondents to the adult survey confirmed that they had asthma. Respondents to the adult survey ranged in age from 18 to 67 years (mean, 43 years). The majority of respondents were women (88%). Respondent race/ethnicity distribution was fairly even with whites comprising 33% of the respondents, blacks 38%, and other 30%. (Respondents could check more than one category.) In addition, 43% of respondents indicated that they were Hispanic. A total of 3,258 respondents (93%) to the child survey reported that their child had asthma. Children ranged in age from 1 to 17 years, with 28% of respondents between the ages of 1 and 5 years, and 72% between 6 and 17 years. Male respondents comprised 59% of the children’s sample. Race and ethnicity distribution was as follows: white, 24%; black, 44%; Hispanic or Latino, 42%; other, 32%.

Health Status and Severity of Asthma
The majority of adults reported that their health was fair or poor (64%) and that their asthma was moderate to very severe (81%). In the previous 3 months, 69% had lost at least 1 day from work or school due to their asthma and had reported moderate or greater difficulty in performing daily activities due to their asthma. Children were reported as being healthier than the adults, with only 27% of parents reporting their child’s health as fair or poor and 65% indicating that their child’s asthma was moderate or very severe. With the exception of the question regarding losing time from work or school, the differences between the adults and child responses were all statistically significant (Table 1 ).


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  		Table 1.. Health Status and Severity of Asthma*

 
Patient Education
The quality of information from providers was rated as "good" or "very good" by 89% of all respondents. Over 80% of respondents reported receiving instruction on each of the following: peak flow meter use; inhaler use; management of asthma exacerbations; and an explanation of aggravating factors. Eighty-one percent of respondents received written instructions regarding medication or what to do in case of a severe asthma attack situation. Seventy percent of respondents said a provider observed them using an inhaler, and 73% said that a provider explained how to adjust medications for severity.

Patient Knowledge
Seventy-one percent of respondents indicated that they knew their optimal peak flow meter reading. Over three-quarters of respondents (77%) indicated they could recognize the factors aggravating their asthma symptoms, and 78% reported that they knew how to respond to an asthma exacerbation. A high proportion of respondents (87%) reported knowing what to do for a severe asthma attack.

Patient Self-Management
The majority of respondents reported taking their medications when needed (84%) and following the care plan prepared by their provider (80%). Slightly over one half of the respondents (excluding children between 1 and 5 years of age) had a peak flow meter (51%). Of those who had a peak flow meter, 63% used it regularly. Thirty-one percent of respondents used a spacer, 32% kept a peak flow diary, and 18% changed their medications based on peak expiratory flow rate readings.

A very high proportion (40%) of the asthmatic respondents responding to our survey smoke cigarettes or are routinely exposed to cigarette smoke. For the adult respondents, 46% either smoke or live in a household where they are exposed to cigarette smoke. For children, the smoking exposure rate is 35%. Smoking rates are highest among whites, women, and those who reside outside of NYC.

Access
Among the six survey items designed to measure perceptions of access to services and equipment, ease of obtaining urgent/emergent care for asthma yielded the highest rate, with 91% reporting easy access. A high proportion of respondents were satisfied with the time they had to wait for an appointment (86%) and the ease with which they could contact their provider by phone (82%). Over 70% of the respondents reported that "ease of obtaining a peak flow meter or a spacer was not a problem."

Satisfaction With Asthma Care
Overall satisfaction with asthma care was rated as "good" or "excellent" by 92% of respondents. Less than 2% of respondents rated the quality of their care as "very poor" during the last 12 months.

Medication Usage
Seventy-five percent of respondents reported that they used inhaled steroids. Among those that did, only 38% used them daily as prescribed by their doctor, 11% used them "less often than their doctor wants," 10% used them several times a week, and 40% used them only when they had symptoms (Table 2 ).


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  		Table 2.. Survey Item Responses*

 
Results of the univariate analysis showed that adults, SSI Medicaid eligibility, white race, living outside of NYC, poor health status, severe asthma, and rating their asthma education as good were all significantly associated with an increased likelihood of daily inhaled steroid use (Table 3 ).


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  		Table 3.. Associations Between Daily Use of Inhaled Steroids and Other Indicators

 
Table 4 presents the results of a multivariate analysis of daily inhaled steroid use. Similar to the univariate results, adults with self-assessed poor health status, those with severe asthma living outside of NYC, and those who rated their asthma education as good were more likely to use inhaled steroids. Hispanics are 1.31 times more likely to take inhaled steroids daily compared to whites, adjusting for other demographic and survey variables (Table 4).


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  		Table 4.. Multivariate Analysis of Daily Use of Inhaled Steroids

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 Appendix
 References
 
The NAEPP released updated guidelines9 for the treatment of asthma in 1997. The guidelines promoted the following four key components for the long-term control of asthma: (1) assessment and monitoring; (2) pharmacologic therapy; (3) control of factors contributing to asthma severity; and (4) patient education.9 This survey yields data from patient self-report that evaluates how well the guidelines are being met, patient compliance with treatments, and the access to, and quality of, the care they have received from their providers and health plan. The discussion that follows links key findings from the survey to the NAEPP guidelines.

Pharmacologic Therapy
Under the NAEPP guidelines, all patients with persistent asthma should be using inhaled corticosteroids on a daily basis. Seventy-five percent of combined adult and child respondents to this survey reported using inhaled steroids, however, only 38% reported daily use (27% of the entire survey population). This number correlates with findings from the NYSDOH focused clinical study conducted in 2000 in which 41% of patients with moderate-to-severe asthma, between the ages of 6 and 39 years, had evidence of using inhaled steroids in their medical records. This finding also has been described in the literature.1011

To verify our findings from self-report, we matched data from this survey to the Medicaid managed care pharmacy database. We found that only 73% of adult respondents who said they used inhaled steroids actually had filled prescriptions for these medications. That number increased to 76% when steroids, anti-inflammatory medications, and leukotrienes also were included. Similarly, with respondents to the children’s survey who answered "yes" to the question about taking inhaled steroids, we have evidence of at least one filled prescription for only 49%. When we add steroids, anti-inflammatory medications, and leukotrienes to that question, the number climbs to 61%. However, we also found that 22% of the adult respondents and 7% of the respondents for children who answered "no" to the question asking whether they used inhaled steroids, actually have filled prescriptions for inhaled steroids. This may indicate they did not understand the question, may not know what medications they are taking, or that they filled the prescription but no longer use the medication (NYSDOH Medicaid encounter data).

Of the respondents who use inhaled steroids, only 38% use them as prescribed/recommended. When we examined demographic factors that might influence compliance, we found that the rate of inhaled steroid use was significantly lower for children than for adults (64% vs 87%, respectively). In addition to the severity differences (children are reported as being healthier), the discrepancy between adult and child inhaled steroid use might be attributable to physician practice patterns, as well as to parental/provider fears regarding the impact of steroids on inhibiting a child’s physical growth.12 While the cost of copayments can sometimes be a deterrent when filling prescriptions, there are no out-of-pocket costs associated with the New York State Medicaid managed care program.

Another possible explanation of this less than optimal rate is that some of the respondents may be using a different class of longer acting controller anti-inflammatory medication in place of inhaled steroids. When examining our Medicaid pharmacy data, we observed that other controller medications (eg, cromolyn and leukotriene modulators) are routinely being prescribed to children. Missed opportunities for the control of children’s asthma with long-term use of controller medications is well-documented in the literature, and may be an area in which health plans and clinicians can focus some of their quality improvement efforts.13

Overall, the majority of respondents (89%) rated the quality of the information provided to them by their doctor, nurse, or other health care provider as good or very good. While most respondents (> 80%) reported that their provider had given them written directions about how to take their medicine, how to use a peak flow meter, and what to do if they experience a severe asthma attack, there appears to be some problems putting this information into practice, as evidenced by the large number of patients who do not take inhaled steroids on a daily basis and do not self-monitor their airway flow rates. Also, while 84% of respondents reported taking their medications when needed, there remained a significant proportion who did not.

Trigger Control
The NAEPP guidelines recommend that patients be educated about how to reduce their exposures to environmental triggers and include recommendations for maintaining a smoke-free household. However, this survey found that the rates of asthmatic patients who smoke or are exposed to smoke in the home are alarmingly high, at 40% for all respondents. Previous clinical studies conducted by the NYSDOH found that documentation of whether a patient smokes was present in only 23% of the medical records and that only 12% of patients were asked about exposure to second-hand smoke. Thus, the combined findings from both studies suggest that clinicians are underidentifying asthmatic patients who smoke or are exposed to smoke.

Assessment and Monitoring
While we found that 51% of respondents had a peak flow meter, only 32% of them kept a peak flow diary, and only 18% adjusted their medications based on peak flow readings. These survey data are consistent with data from our 2000 focused clinical study, in which we found evidence in the medical record of 11% of patients using a peak flow meter. Research in this area is mixed, with some studies showing reduced asthma-related morbidity for asthmatic patients who monitor their breathing by using peak flow meters,14 and others showing no differences.15 Most studies indicate that peak flow monitoring should be done only for those patients with moderate-to-severe persistent asthma. The latest NAEPP guidelines call for more study in this area to determine the usefulness of peak flow monitoring.11 Further evidence may convince physicians to promote this monitoring tool to their patients with asthma.

Assessing Asthmatic Patients Experience With Care
Overall satisfaction with care was high, although when separately analyzed by health status, those persons reporting fair or poor health reported lower levels of satisfaction. This finding is consistent with other findings reported in the literature16 on the relationship between health status and satisfaction. Access to medical services was not perceived as a problem among the respondents to this survey. Seventy percent reported ease in obtaining a specialist referral. Thirty-seven percent of respondents were seen by a specialist in the last 12 months, however, from this study it is not known how many of the respondents saw a specialist > 1 year ago. It is difficult to determine what the "optimal rate" for this measure is. The NAEPP recommends that asthmatic patients with distinct management problems or conditions that complicate asthma should be referred to a specialist. With the information gathered for this survey, we were unable to determine how many of the respondents fit this category.

Limitations of This Survey
A potential limitation of this study was the low response rate of 28%. To account for this, the results presented in this article have been adjusted by Medicaid aid category and race/ethnicity to better represent the survey population, and to account for different response rates for these subgroups. In addition, a sample of nonresponders was contacted by phone to see whether they differed from those who responded to the survey. A total of 602 survey nonresponders agreed to answer select questions from the survey over the phone. Persons in the telephone follow-up were significantly less likely than survey responders to say that they had ever had asthma (75% vs 94%, respectively). Phone respondents reported having less severe asthma than did mail respondents (57% vs 72%, respectively) and were also more likely to be satisfied with their care (95% vs 92%, respectively). These results may suggest that persons who responded had more severe asthma than those who did not respond. The two groups did not differ significantly on gender, race, or knowledge of how to handle a severe asthma attack. Finally, a response rate of 28%, while low, compared favorably to other mail-only surveys of the Medicaid population such as the Consumer Assessment of Health Plans Survey, which averages 27% for adults nationwide (Russell E. Mardon, PhD; personal communication; August 27, 2003).

Some of the eligibility criteria that we used for inclusion into this study (ie, inpatient care and emergency department use) deliberately included those Medicaid recipients whose asthma may not be under good control while excluding those recipients whose asthma is under control and well-managed. Therefore, our findings may only apply to those Medicaid recipients with moderate-to-severe asthma and may not be generalizable to asthmatic patients with milder forms of the disease. Another potential limitation is that of recall bias. Many of the questions we posed in the survey relied on respondent memory of what took place during a visit that may have occurred more than a year before they received the survey. Related to the recall bias is that often respondents to surveys may report what they believe is the "right" answer, that is, what they have been instructed to do.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
Appendix
 References
 
The majority of Medicaid managed care enrollees with asthma who responded to our survey rated the quality of the care they received very highly. They reported relative ease in accessing their providers for appointments and phone consultation, and in accessing urgent and emergency care when needed.

While the reported use of inhaled steroid use was high, the majority of respondents are not using the therapy as it was prescribed and instead are using it incorrectly as a "rescue drug." Furthermore, while we report high rates of providers educating their patients, and high rates for the quality of the information presented to patients, comprehension, as evidenced by daily inhaled corticosteroid use, is less than optimal. In this study, we found that respondents who use inhaled corticosteroids on a daily basis are the ones who rank the quality of the information provided by their doctor or nurse higher than those who do not, thereby demonstrating a link between effective communication and education, and compliance with treatment regimens.

A significant challenge remains in motivating patients to take preventive medicine during times when they are asymptomatic. This may be especially true for medications that are perceived by many patients to have potential adverse effects. This challenge is common to other chronic conditions such as hypertension, congestive heart failure, and diabetes.

Based on the results of this survey, we recommend that future asthma-related quality improvement efforts be focused on the quality of the education surrounding medication adherence. For example, recently published research has demonstrated that patients with low socioeconomic status with poor medication adherence improve adherence when provided with direct clinician-to-patient feedback discussion at each visit.17 Health plans and providers need to focus on the disparity between what people report understanding and what they actually do. New York State will be assisting physicians in addressing some of these issues by adopting a statewide asthma guideline, (based on the National Institutes of Health guidelines) that has been endorsed by all the major insurers, and by conducting regional trainings across the state.

Finally, we would also note the very high rates of tobacco smoke found in the households of respondents to this survey. While there has been a significant amount of time taken and attention given to this issue, the problem of tobacco addiction/dependence and secondhand smoke exposure for individuals with chronic disorders continues to present significant challenges to the health-care system, and may require new approaches.


   Appendix
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix
References
 



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   Acknowledgements
 
The authors acknowledge the contributions of Dr. Jill Karpel, Paul Henfield, Jacqueline Butch, Peter Lannon, Beverly Pasley, and Laurie Fahrenkopf in the development and editing of this manuscript.


   Footnotes
 
Abbreviations: FACCT = Foundation for Accountability; NAEPP = National Asthma Education and Prevention Program; NYC = New York City; NYSDOH = New York State Department of Health; SN = Safety Net; SSI = Supplemental Security Income; TANF = Temporary Assistance to Needy Families

Received for publication April 4, 2003. Accepted for publication October 30, 2003.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix
 References
 

  1. Piecoro, LT, Potoski, M, Talbert, JC (2001) Asthma prevalence, cost and adherence with expert guidelines on the utilization of health care services and costs in a state Medicaid population. Health Serv Res 36,357-371[ISI][Medline]
  2. Crim, C Clinical practice guidelines vs actual clinical practice: the asthma paradigm. Chest 2000;118 (suppl),62S-64S
  3. Scarfone, RJ, Zorc, JJ, Capraro, GA Patient self-management of acute asthma: adherence to national guidelines a decade later. Pediatrics 2001;108,1332-1338[Abstract/Free Full Text]
  4. Agency for Healthcare Research and Quality. CAHPS and the National CAHPS benchmarking database: fact sheet. Available at: http://www.ahrq.gov/qual/cahpfact.htm. Accessed March 15, 2004
  5. The Foundation for Accountability. FACCT quality measures measurement guide, adult asthma: 1999. Available at: http://www.facct.org/facct/doclibfiles/documentfile_307.pdf. Accessed January 21, 2004
  6. Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System online prevalence data: 1995–2001. Available at: http://www.cdc.gov/brfss/questionnaires. Accessed March 15, 2004
  7. Diette, GB, Wu, AW, Skinner, EA, et al Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids. Arch Intern Med 1999;159,2697-2704[Abstract/Free Full Text]
  8. SAS Institute. SAS statistical software (release 8.0). 1999 SAS Institute Inc. Cary, NC:
  9. National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, April 1997; Publication No. 97–4051
  10. Legorreta, AP, Christian-Herma, J, O’Connor, RD, et al Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience. Arch Intern Med 1998;158,457-468[Abstract/Free Full Text]
  11. Bartlett, SJ, Lukk, P, Butz, A, et al Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma 2002;39,47-54[CrossRef][ISI][Medline]
  12. Cabana, MD, Rand, CS, Becher, OJ, et al Reasons for pediatrician non-adherence to asthma guidelines. Arch Pediatr Adolesc Med 2001;155,1057-1062[Abstract/Free Full Text]
  13. Adams, RJ, Fuhlbrigge, A, Finkelstein, JA, et al Use of inhaled anti-inflammatory medications in children with asthma in managed care settings. Arch Pediatr Adolesc Med 2001;155,501-507[Abstract/Free Full Text]
  14. Ignacio-Garcia, JM, Gonzalez-Santos, P Asthma self-management education program by home monitoring of peak expiratory flow. Am J Respir Crit Care Med 1995;151,353-359[Abstract]
  15. Drummond, N, Abdalla, M, Beattie, JA, et al Effectiveness of routine self-monitoring of peak-flow in patients with asthma. BMJ 1994;308,564-567[Abstract/Free Full Text]
  16. Zaslavsky, AM, Zaborski, L, Cleary, PD Does the effect of respondent characteristics on consumer assessments vary across health plans. Med Care Res Rev 2000;57,379-394[Abstract/Free Full Text]
  17. Onyirimba, F, Apter, A, Reisine, S Direct clinician-to-patient feedback discussion of inhaled steroid use: its effect on adherence. Ann Allergy Immunol 2003;90,411-415



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