Discussion
In this cohort of pediatric ED visits, only approximately half of EAI prescriptions were filledfollowing ED discharge.NH-white children were more likely to have EAI prescriptions filled after an ED visit for anaphylaxis than NH-blackchildren and patients with private insurance were more likely than patients with in-state Medicaid to fill an EAI prescription. However, when adjusting for multiple variables, these differences were no longer significant.
The low EAI fill rate is this study is inconsistent with a previous study that estimated pediatric EAI fill rates closer to 90%;however, this studyincluded only patients with private insurance.13Similar to our population, previous large database adult studies that include patients with a variety of pharmacy coverage have found that approximately half of patients fill their EAI.14It’s likely that the EAI fill rate in our study was more similar to that seen in adult data because of the diversity of insurance and/or socioeconomic status in our population. While insurance type may be a specific barrier to prescription filling, it may also be a marker for lower socioeconomic status, which can confer an independent risk factor for low filling rates if for instance, pharmacies in low-income areas are less likely to carry EAIs or patients of lower socioeconomic status are less likely to have transportation to get to a pharmacy.
Identifying risk factors associated with poor rates of EAI prescription filling is imperative to create targeted strategies for improving them. The objective of this study was to identify predictors associated with EAI prescription filling. We found that while NH-white patients had a higher fill rate compared to NH-blackpatients and having in-state public insurance was associated with a lower fill rate than having private insurance, there was likely a concordance between being NH-blackand having public in-state insurance.This is consistent with the knowledge that minority children are significantly more likely to have public insurance compared to white children.15Interestingly, patients with out-of-state Medicaid did not have the same risk of low fill rates as those patients with in-state Medicaid. This study was conducted in Washington, DC which is unique in that in-state Medicaid is restricted to District of Columbia residents and therefor encompasses an entirely urban population; whereas out-of-state Medicaid is likely to be held by patients living in the Maryland and Virginia suburbs.
In order to address low fill rates of EAI prescriptions, further studies should be aimed at assessing to what extent disparities in filling are related to patient education, medication availability and cost. In addition to targeting interventions aimed at educating patients at risk for not filling EAI prescriptions, interventions aimed at improving EAI fill rates should consider changes to the system that is serving largely minority and publicly insured patients.16For instance, providingan EAI on discharge from the ED as an alternative to providing a prescription or partnering with local pharmacies to determine availability may be beneficial.