Are children with asthma prescribed too many OCSs?

An analysis of 2015 claims data for about 69,000 children with an asthma diagnosis suggests that the answer to this question is “yes.” Of these children, who were insured through a large Texas health plan for children with Medicaid and CHIP and who ranged in age from 1 to 18 years, 42.1% were given an oral corticosteroid (OCS) 1 or more times during the year; 9.9%, 2 or more times; and 3.3%, 3 or more times. Yet the medical histories of these children did not suggest poor asthma control.

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Children aged younger than 5 years were most likely to be given an OCS; 49% of patients in this age group had 1 or more OCS events compared with 38% of children who were aged 5 years or older. (The OCS dispensing rates were lower for African American children than for white or Hispanic children.) Despite these high rates of OCS use, only 18.6% of those given an OCS had 1 or more risk factors for poorly controlled asthma: 7.3% had an emergency department (ED) visit for asthma; 0.73% had an asthma hospitalization; and 14.3% had received 4 or more short-acting beta-agonist canister equivalents.

Prescribing rates varied substantially with the type of primary care provider the child had, although OCS prescriptions measured could have been written by either a primary care provider or another practitioner. Rates were lowest when the primary care provider was a board-certified pediatrician rather than a non–board certified pediatrician, internist, or family or general practitioner. Further, among pediatricians-whether or not they were board certified-rates of OCS dispensing varied widely, from 15% to 86%. Yet this variation in OCS dispensing rates was not associated with rate differences in hospitalization or ED visits.

A comparative analysis of corresponding data for the 4 preceding years (2011-2014) yielded similar results (Farber HJ, et al. Pediatrics. 2017;139[5]:e20164146).

Thoughts from Dr Burke

In this Texas health plan, a large percentage of children with asthma were given oral steroids each year. Prescription rates varied broadly, suggesting lack of clearly defined and generally accepted guidelines in the community. To be fair, guidelines for use of steroids in mild to moderate exacerbations are flexible. However, most significant, perhaps, few of the patients who received OCSs in the study period were given inhaler steroids as a control medication during the same year (22% in 2015). In an accompanying editorial (Pediatrics. 2017;139[5]:e20170598), Michael Cabana, MD, concludes, “OCS overuse may be merely a symptom of another important prescribing issue; that is, the underuse of [inhaled corticosteroids] for children with persistent asthma.”