Division of Pediatric Pulmonology, Norton Children's and University of Louisville School of Medicine, Louisville, KY.
Division of Pediatric Pulmonology, Norton Children's and University of Louisville School of Medicine, Louisville, KY.
J Pediatr. 2021 Jul;234:128-133.e1. doi: 10.1016/j.jpeds.2021.03.008. Epub 2021 Mar 10.
To evaluate the impact of a payor-initiated formulary change in inhaled corticosteroid coverage on lung function in patients with asthma and on provider prescribing practices. This formulary change, undertaken in August 2016 by a Medicaid payor in Kentucky, eliminated coverage of beclomethasone dipropionate, a metered dose inhaler (MDI), in favor of mometasone furoate, available as MDI and dry powder inhaler (DPI).
A retrospective chart review was conducted on children with asthma ages 6-18 years covered by the relevant payor from a university-based pediatric practice who were seen before the formulary change (February to July 2016) and after (February to July 2017). Spirometry data from each visit was compared using the paired Student t test.
Fifty-eight patients were identified who were initially on beclomethasone dipropionate and had spirometry available at both visits. Those who switched from an MDI to a DPI (n = 24) saw a decline in median predicted forced expiratory volume in 1 second from 98.5% to 91% (P = .013). A decline was also seen in forced expiratory flow at 25%-75%, from 89.5% predicted to 76% predicted (P = .041). No significant changes were observed in children remaining on an MDI. Seven patients discontinued inhaled corticosteroid therapy.
This study suggests insurance formulary changes leading to use of a different inhaler device may have a detrimental impact on pediatric lung function, which may be a surrogate measure for overall asthma control. This could be due to a lack of adequate timely educational intervention as well as the inability of some children to use DPIs.
评估由支付方发起的吸入性皮质类固醇覆盖范围的医保目录变更对哮喘患者肺功能和医疗服务提供者处方行为的影响。肯塔基州的一个医疗补助支付方于 2016 年 8 月进行了这一医保目录变更，用莫米松糠酸酯（MDI 和干粉吸入器，DPI）替代丙酸倍氯米松（MDI），取消了丙酸倍氯米松的覆盖范围。
对一家大学儿科诊所中接受相关支付方保险的年龄在 6-18 岁的哮喘患儿进行回顾性图表审查，这些患儿在医保目录变更前（2016 年 2 月至 7 月）和变更后（2017 年 2 月至 7 月）均有就诊。使用配对学生 t 检验比较每次就诊的肺活量数据。
共确定了 58 名最初使用丙酸倍氯米松且两次就诊均有肺活量数据的患者。从 MDI 切换到 DPI 的 24 名患者的中位预计 1 秒用力呼气量从 98.5%下降至 91%（P=0.013）。用力呼气流量在 25%-75%之间也出现下降，从 89.5%预计值降至 76%预计值（P=0.041）。继续使用 MDI 的儿童未观察到显著变化。有 7 名患者停止使用吸入性皮质类固醇治疗。
这项研究表明，导致使用不同吸入装置的医保目录变更可能对儿科肺功能产生不利影响，这可能是整体哮喘控制的替代指标。这可能是由于缺乏及时的充分教育干预，以及一些儿童无法使用 DPI。
