"Overall, we found plenty of room for improvement in the care of children with asthma, but comparing types of insurance had some interesting results," says lead author Timothy G. Ferris, MD, MPH, a pediatrician at MGH. "We found no evidence that there's worse quality of care for children with managed care who present to the emergency department with acute asthma. And in one area that we looked at, we found evidence for better quality."
The study used a national sample of 965 children visiting 36 different emergency departments for asthma treatment. The researchers compared quality of pre-emergency department care, acute severity and short-term outcomes across four different insurance categories: managed care, indemnity, Medicaid and uninsured.
When comparing indemnity and managed care plans, the only significant area of difference was that a child with managed care was more likely to see his primary care physician before going to the emergency department. "Those with managed care plans were almost twice as likely to see their primary care physicians in the week prior to an emergency department visit," says Ferris. "This provides evidence that managed care may be effectively shunting cases away from the emergency department and to the primary care physician." Ferris says that's an important accomplishment, because patients with asthma often use the emergency department inappropriately for treatment.
The results also suggested that children in managed care plans may have more appropriate emergency department visits for asthma. The researchers found that managed care patients seen in the emergency department were sicker than patients with other types of insurance, but at the same time managed care patients had similar lengths of stay in the hospital and similar likelihood of having persistent symptoms. "If the outcomes were worse for managed care patients, we'd be concerned that managed care restrictions on emergency department use were hurting patients with asthma," Ferris says. "But we did not find evidence of this."
In an unadjusted analysis, the study results also showed that quality of care was worse under Medicaid plans compared to other insurance plans. But when factors such as parent income and education were taken into account, the differences between Medicaid and other types of insurance largely disappeared.
Patients who were uninsured received the poorest quality of care by far. They also often came into the emergency department during non-emergency situations. "They were probably using the emergency department inappropriately because they had no other place to go," says Ferris. He stresses that the study adds to the growing body of literature demonstrating how patients' insurance status affects their access to quality outpatient care.
The study was conducted as part of the Multicenter Airway Research Collaboration (MARC), a network of emergency departments that cooperate in studies and trials designed to evaluate and improve the care of emergency patients with respiratory problems. MARC was founded and led by the study's principal investigator, Carlos Camargo Jr, MD, an MGH emergency physician and epidemiologist. Other researchers in the study include Linda Wang, MD, and Sunday Clark, MPH, MGH Emergency Department; Emily Oken, MD, Brigham and Women's Hospital; and Ellen Crain, MD, PhD, Albert Einstein College of Medicine. The study was supported by the Pediatric Scientist Development Program, the National Institutes of Health, Glaxo Wellcome Inc., and Monaghan Medical Corporation.
The Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $300 million and major research centers in AIDS, the neurosciences, cardiovascular research, cancer, cutaneous biology, photomedicine, transplantation biology. In 1994, the MGH joined with Brigham and Women's Hospital to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups and non acute and home health services.
Journal
Ambulatory Pediatrics