Race, insurance associated with adherence to biologic prescriptions for asthma
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Key takeaways:
- 77.6% of Black patients and 88.4% of white patients with a prescription received a dose of a biologic.
- 74.3% of patients on Medicaid and 88.8% of patients with commercial insurance received a dose.
Black patients and those on Medicaid had lower rates of adherence to biologics prescribed for asthma, often due to patient-level barriers, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
However, these factors did not impact whether these prescriptions were issued, Patrick K. Gleeson, MD, MSCE, instructor A of medicine, section of allergy and immunology, division of pulmonary, allergy and critical care medicine, Perelman School of Medicine, and colleagues wrote.
The retrospective, observational cohort study involved 8,057 adults (29.4% men; 65% white, 30.6% Black) who were patients at Penn Medicine with asthma, including 306 (3.8%) who received a prescription for a biologic.
The patients who were prescribed biologics were more likely to be younger and men, and they were more likely to have commercial insurance than those patients who did not receive prescriptions for biologics, the researchers wrote.
In the 12 months before their first visit with a specialist, Black patients reported more oral corticosteroid (OCS) bursts as well as five times more hospitalizations and 15 times more ED visits for asthma than white patients.
Patients with high Area Deprivation Index (ADI) scores, indicating greater vulnerability, and patients who were on Medicaid instead of commercial insurance experienced similar trends, the researchers wrote.
The multivariable analysis, which included 8,026 patients who all were white, Black or Asian, found associations between receiving a biologic prescription and having at least one ED visit (OR = 1.82; P = .03) or hospitalization (OR = 2.91; P < .001) for asthma during the year before the prescription.
Also, the researchers reported associations between prescriptions and having two or three (OR = 1.9; P < .001) or four or more (OR = 3.01; P < .001) OCS bursts in the year before the first visit with a specialist.
Patients with nasal polyposis were 4.87 times more likely (P < .001) to get a prescription as well, while women (OR = 0.66; P = .002) and current smokers (OR = 0.5; P = .04) were less likely to get a prescription.
Penn Medicine providers prescribed biologics to 262 of the 335 patients who received prescriptions in the cohort at least 12 months before the end of the study period, with complete biologic dispensing data available for 238 of them.
The median number of days from prescription to first dose in these 238 patients was 32.5, with a mean of 57.8 (standard deviation = 67.8). The 36 patients who did not receive a dose did not have any documentation for why they did not receive one.
Patient-level barriers accounted for 26 (72.2%) of the cases where patients did not receive a biologic, including patients lost to follow-up (22%), patients who felt the cost was prohibitive (14%) and patients who were nervous about or fearful of receiving the biologic (11%), among other reasons.
Health insurance denials accounted for eight (22.2%) of the cases where patients did not receive a biologic, due to reasons such as failure to meet laboratory criteria or inadequate documentation (8%) or documentation of controller inhaler nonadherence (6%), and provider decisions were responsible for two (5.6%) of the cases.
Based on a multivariable analysis, patients who were Black (incidence rate ratio [IRR] = 0.85; P < .001) and patients on Medicaid insurance (IRR = 0.86; P < .001) were less likely to obtain a dose.
Specifically, 77.6% of Black patients and 88.4% of white patients received a dose, as did 74.3% of those on Medicaid and 88.8% of those with commercial insurance. Class III obesity was associated with fewer days covered compared with normal BMI (IRR = 0.81; P = .005) as well.
The multivariable analysis also found associations between fewer days covered and Medicaid insurance (IRR = 0.87; P = .01) compared with commercial insurance, with medians of 98 days for Medicaid patients and 224 days for commercial patients.
The 202 patients with complete biologic dispensing data and at least one dose of a biologic had fewer OCS bursts in the 12 months following the biologic prescription compared with before the prescription, including a greater number of patients with no bursts or one burst after the prescription and fewer patients with two or more bursts.
By percentages, 53.8% who had four or more bursts before the prescription had zero to three bursts after; 56.2% of those with two or three bursts before had zero bursts or one burst after; and 36.2% of patients with one burst before had no bursts after.
Overall, 3.8% of the full cohort had received a prescription for a biologic, and 84.9% received a dose within 12 months, with patient-level barriers leading to more non-adherence than insurance denials.
Based on these findings, the researchers said social determinants of health may drive primary adherence to biologics, although further studies are needed to confirm whether these results can be generalized to other health systems.
The researchers also encouraged health providers to work to alleviate these barriers and provide adequate information and education to patients so they can make informed decisions about biologic use.
Perspective
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I do not necessarily think the findings that Black patients and those with Medicaid insurance were associated with lower rates of primary adherence to biologics nor, unfortunately, that less than 4% were prescribed a biologic for asthma, are surprising.
The findings do continue to shine a light on inequities in use of prescribed asthma biologics and further help to identify potential social determinants of health contributing to the inequities. But the low rate of use also indicates the problem is not just limited to patient level factors, as there continues to be significant clinical inertia and providers who do not adequately prescribe these treatments.
Also, the findings that increased severity and being a minority were related to increased adherence are comparable to our research. In our study, we did not examine primary non-adherence. But we did find that adherence depended on administration setting, which was not assessed in the current study.
Doctors should be aware that minorities and those on Medicaid can still get these medications covered. Also, doctors should be aware that any potential implicit bias that they will not be able to access these medications is not well founded in these data.
These medications are under-prescribed, but further focus on assessing the social determinants of health is not needed. Instead, clinical inertia needs to be considered.
Additionally, given the time delay in filling a first prescription, doctors should consider following up with patients shortly after issuing these prescriptions to reduce potential non-primary adherence.
To help patients overcome these barriers to care, doctors should determine if the individual should be initiated on asthma biologic treatment. We also should encourage providers to consider use of these medications, given the continued barrier of clinical inertia.
In addition, from a patient perspective, efforts to improve asthma biologic adherence should consider promoting self-administration when beneficial, improving prior specialist access and targeting patients with higher risk of suboptimal adherence, particularly Black and Hispanic patients.
Next, researchers should consider testing health care delivery models that help better identify potential individuals who may benefit from these treatments, but also help facilitate patient access, adherence and self-management with treatment. To ensure such interventions are sustainable, evaluation of the impact on patient and health care resources would be necessary.
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