Exploring the use of pharmaceutical patient assistance programs as an option to improve access to and affordability of prescription drugs

Background. Pharmaceutical-sponsored patient assistance programs (PAPs) are charity programs that provide free or reduced-priced medications to eligible patients. PAPs have the potential to improve prescription drug accessibility for patients but currently there is limited information about their use and effectiveness. ^ Objectives and methods. This dissertation described the use of PAPs in the U.S. through the conduct of two studies: (1) a systematic review of primary studies of PAPs from commercially-published and “grey” literature sources; and (2) a retrospective, cross-sectional study of cancer patients' use of PAPs at a tertiary care cancer outpatient center. ^ Results. (1) The systematic review identified 33 studies: 15 evaluated the impact of PAP enrollment assistance programs on patient healthcare outcomes; 7 assessed institutional costs of providing enrollment assistance; 7 surveyed stakeholders; 4 examined other aspects. Standardized mean differences calculated for disease indicator outcomes (most of which were single group, pre-posttest designs) showed significant decreases in glycemic and lipid control, and inconsistent results for blood pressure. Grey literature abstracts reported insufficient statistics for calculations. Study heterogeneity made weighted summary estimates inappropriate. Economic analyses indicated positive financial benefits to institutions providing enrollment assistance (cost) compared to the wholesale value of the medications provided (benefit); analyses did not value health outcomes. Mean quality of reporting scores were higher for observational studies in commercially-published articles versus full text, grey literature reports. (2) The cross-sectional study found that PAP outpatients were significantly more likely to be uninsured, indigent, and < 65 years old than non-PAP patients. Nearly all non-PAP and PAP prescriptions were for non-cancer conditions, either for co-morbidities (e.g., hypertension) or the management of treatment side effects (e.g., pain). Oral chemotherapies from PAPs were significantly more likely to be for breast versus other cancers, and be a newer, targeted versus traditional chemotherapy.^ Conclusions. In outpatient settings, PAP enrollment assistance plus additional medication services (e.g., counseling, reminders, and free samples) is associated with improved disease indicators for patients. Healthcare institutions, including cancer centers, can offset financial losses from uncompensated drug costs and recoup costs invested in enrollment assistance programs by procuring free PAP medications. Cancer patients who are indigent and uninsured may be able to access more outpatient medications for their supportive care needs through PAPs, than for cancer treatment options like oral chemotherapies. Because of the selective availability of drugs through PAPs, there may be more options for newer, oral, targeted chemotherapies for the treatment breast cancer versus other for other cancers.^

Doctor-patient communication in the medical interaction: Context, implications, and practice

Effective communication; whether from an interpersonal, mass media, or global perspective, is a critical component in public health. It is an essential conduit in increasing public awareness of available health resources, potential health hazards and related disease prevention strategies, and in delivering better health care. Within this context, available literature asserts doctor-patient communication as central to healthcare delivery. It has been shown to affect patient health outcomes, satisfaction with care, adherence to treatment recommendations, and even understanding of medical information. While research supports the essential imperative of interventions aimed at teaching doctors and patients the communication skills necessary for a successful and meaningful medical interaction, most interventions to date, focus on teaching these communication skills to doctors and seem to rely, largely, on mass media for providing patients with the information needed to increase communication efficacy. This study sought to fill a significant gap in the doctor-patient communication literature by reviewing the context of the doctor-patient exchange in the medical interaction, the implications of this exchange in resulting care of the patient, and the potential improvements to practice through interventions aimed at improving the communication exchange. Closing with an evaluation of a patient-centered communication intervention, the “How to Talk to Your Doctor” (HTTTYD) program that combines previously identified optimal strategies for improving communication between doctors and patients, this study examined the patients’ perspective of their potential as better communicators in the medical interaction. ^ Specific Aims, Hypotheses or Questions (Aim I) To examine the context of health communication within a public health framework and its relation to health care delivery. (Aim II) To review doctor-patient communication as a central focus within health care delivery and the resulting implications to patient care. (Aim III) To assess the utility of interventions to improve doctor-patient communication. Specifically, to evaluate the effectiveness of a patient-centered community education intervention, the “How to Talk to Your Doctor” (HTTTYD) program, aimed at improving patient communication efficacy.^

Treatment discontinuation among breast, colorectal, and prostate cancer patients in Alabama

Introduction. Cancer registries provide information about treatment initiation but not the full course of treatment. In an effort to identify patient reported reasons for discontinuing cancer treatment, patients with prostate, breast, and colorectal cancer were identified from Alabama State Cancer Registry (ASCR) -Alabama Medicare linked database for interview. This study has two specific aims: (1) determine whether the ASCR-Medicare database accurately reflects patients’ treatment experiences in terms of whether they started and completed treatment when compared to patient self-report and (2) determine which patient demographic and health care system factors are related to treatment completion as defined by patient self-report. ^ Methods. The ASCR-Medicare claims dataset supplemented patient interview responses to identify treatment initiation and completion among prostate, breast, and colorectal cancer patients in Alabama from 1999-2003. Kappa statistic was used to test for concordance of treatment initiation and completion between patient self-report and Medicare claims data. Patients who reported not completing treatment were asked questions to ascertain reasons for treatment discontinuation. Logistic regression models were constructed to explore the association of patient and tumor characteristics with discontinuation of radiation and chemotherapy. ^ Results. Overall, there was a fair agreement across all cancer sites about whether one had surgery (Kappa=.382). There was fair agreement between self-report and Medicare claims data for starting radiation treatment (Kappa=.278). For starting chemotherapy there was moderate agreement (Kappa=.414). There was no agreement for completing treatment for radiation and chemotherapy between the self-report and claims data. Patients most often reported doctor’s recommendation (40% for radiation treatment and 21.4% for chemotherapy) and side effects (30% for radiation treatment and 42.8% for chemotherapy) for discontinuing treatment. Females were less likely to complete radiation than males (OR=.24, 95% CI=.11–.50). Stage I patients were more likely to drop radiation treatment than stage III patients (OR=3.34, 95% CI=1.12–9.95). Younger patients were more likely to discontinue chemotherapy than older patients (OR=2.84 95%, CI=1.08–7.69) and breast cancer patients were less likely to discontinue chemotherapy than colorectal patients (OR=.13, 95% CI=.04–.46). ^ Conclusion. This study reveals that patients recall starting treatment more accurately than completing treatment and that there are several demographic and tumor characteristics that influence treatment discontinuation. Providing patients with treatment summaries and survivorship plans can help patients their follow-up care when there are gaps in treatment recall and discontinuation of treatment.^

A comparison of labor and delivery management activities in two settings

Similarities and differences in management activities and patient health outcomes between a traditional physician staffed labor and delivery setting and a certified nurse-midwife staffed Birth Center within the same hospital were described. The 950 study subjects, low income, minority women, were classified as low obstetrical risk by a POPRAS score of 25 points or less at time of admission for labor and delivery. The study subjects were similar in demographic, antepartum and intrapartum characteristics; the labor course was problem free for the majority in both settings. There were no remarkable differences in health outcomes between the groups. Management activities varied between settings; these variations were policy related rather than health related. The POPRAS rating system was an accurate predictor for 93% of BC subjects and 85% of LDU subjects. Charge for service was approximately $600 less for BC women; length of stay did not contribute to the difference in charge. Overall, BC respondents to the attitude survey were more satisfied with their labor and delivery experience than L\&DU women. ^

Patient Characteristics and Outcomes of Gastrointestinal Stromal Tumor Patients Undergoing Imatinib Plasma Level Testing

Although gastrointestinal stromal tumor (GIST) is effectively treated with imatinib, there are a number of clinical challenges in the optimal treatment of these patients. The plasma steady-state trough level of imatinib has been proposed to correlate with clinical outcome. Plasma imatinib level may be affected by a number of patient characteristics. Additionally, the ideal plasma trough concentration of imatinib is likely to vary based on the KIT genotype (genotype determines imatinib binding affinity) of the individual patient. Patients’ genotype or plasma imatinib level may influence the type and duration of response that is appreciable by clinical evaluation. The objectives of this study were to determine effects of genotype on the type of response appreciable by current imaging criteria, to determine the distribution of plasma imatinib levels in patients with GIST, to determine factors that correlate with plasma imatinib level, to determine the incremental effects of imatinib dose escalation; and to explore the median plasma levels and outcomes of patients with various KIT mutations. We therefore obtained KIT mutation information and analyzed CT response for size and density measurement of GISTs at baseline and within the first four moths of imatinib treatment. In 126 patients with metastatic/unresectable disease, the KIT genotype of patients’ tumor was significantly associated with unique response characteristics measurable by CT. Furthermore, hepatic and peritoneal metastases differed in their response characteristics. A subgroup of patients with KIT exon 9 mutation, who received higher doses of imatinib and experienced higher trough imatinib levels, experienced improved progression-free survival similar to that of KIT exon 11 patients. Therefore, we have found that imatinib plasma levels were higher in patients with elevated Aspartate amino transferase, were women, were older, or were being treated concomitantly with CYP450 substrate drugs. As expected, CYP450 inducers correlated with a lower plasma imatinib levels in GIST patients. Renal metabolism of imatinib accounts for <10%, so it was not included in the analysis but may affect covariates. Interestingly, there was a trend for low imatinib levels and inferior progression-free survival in patients who had undergone complete gastrectomy. Patients with KIT exon 9 mutation in our cohort received higher imatinib doses, experienced higher trough imatinib levels, and experienced a PFS similar to that of KIT exon 11 patients. In conclusion, imatinib plasma levels are influenced by a number of patient characteristics. The optimal imatinib plasma level for individual patients is not known but is an area of intense investigation. Our study confirms patients with KIT exon 9 mutations benefit from high-dose imatinib and higher trough imatinib levels.

Management and outcomes of anorectal infection in the cancer patient

Background. The objective of this retrospective cohort study is to examine the presentation and outcomes for a contemporary series of cancer patients with anorectal infection. In addition, we seek to identify factors which are associated with surgical intervention. ^ Methods. The study cohort was identified from ICD-9 codes for diagnosis of infection of the anal and rectal region and patients who underwent a surgical oncology consultation between 1/2000 and 12/2006. Clinical presentation, treatment rendered, and outcomes were retrospectively recorded. ^ Results. Of the 100 patients evaluated by the surgical oncology service for anorectal infection, 42 were treated non-operatively and 58 underwent surgical intervention. Factors associated with surgical intervention based on logistic multivariable analysis included the diagnosis of an abscess (odds ratio [OR] 10.5; 95% confidence interval [CI] 2.9-38.5) and the documentation of erythema on physical examination (OR 3.1; 95% CI 1.1-8.4). Thrombocytopenia (platelets < 50,000) was associated with non-operative management (OR 0.3; 95% CI 0.1-0.7). Incision and drainage was the most common surgical procedure (79%) while a wide debridement for a necrotizing soft tissue infection was required in 2 patients. Infection-specific 90-day mortality was only 1% (N=1). However, the median overall survival for the entire cohort was only 14.4 months (95% CI 7.9-19.5). ^ Conclusions. Non-operative management is a reasonable treatment option for anorectal infection in patients with cancer. Identification of an abscess, erythema on physical exam, and thrombocytopenia were associated with management strategy. Although rare, necrotizing soft tissue infections are associated with significant mortality. ^

Racial disparities in patient survival after liver transplantation in the United States

Background. Racial disparities in healthcare span such areas as access, outcomes after procedures, and patient satisfaction. Previous work suggested that minorities experience less healthcare and worse survival rates. In adult orthotopic liver transplantation (OLT) mixed results have been reported, with some showing African-American recipients having poor survival compared to Caucasians, and others finding no such discrepancy. ^ Purpose. This study’s purpose was to analyze the most recent United Network for Organ Sharing (UNOS) data, both before and after the implementation of the Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) scoring system, to determine if minority racial groups still experience poor outcomes after OLT. ^ Methods. The UNOS dataset for 1992-2001 (Era I) and 2002-2007 (Era II) was used. Patient survival rates for each Era and for adult and pediatric recipients were analyzed with adjustment. A separate multivariate analysis was performed on African-American adult patients in Era II in order to identify unique predictors for poor patient survival. ^ Results. The overall study included 66,118 OLT recipients. The majority were Caucasian (78%), followed by Hispanics (13%) and African-Americans (9%). Hispanic and African-American adults were more likely to be female, have Hepatitis C, to be in the intensive care unit (ICU) or ventilated at time of OLT, to have a MELD score ≥23, to have a lower education level, and to have public insurance when compared to Caucasian adults (all p-values < 0.05). Hispanic and African-American pediatric recipients were more likely have public insurance and less likely to receive a living donor OLT than were Caucasian pediatric OLT recipients (p <0.05). There was no difference in the likelihood of having a PELD score ≥21 among racial groups (p >0.40). African-American adults in Era I and Era II had worse patient survival rates than both Caucasians and Hispanic (pair-wise p-values <0.05). This same disparity was seen for pediatric recipients in Era I, but not in Era II. Multivariate analysis of African-American recipients revealed no unique predictors of patient death. ^ Conclusions. African-American race is still a predictor of poor outcome after adult OLT, even after adjustment for multiple clinical, demographic, and liver disease severity variables. Although African-American and Hispanic subgroups share many characteristics previously thought to increase risk of post-OLT death, only African-American patients have poor survival rates when compared to Caucasians. ^

DOES THE MESSAGE MATTER? ENHANCING PATIENT ADHERENCE THROUGH PERSUASIVE MESSAGES

To improve health and reduce costs, we need to encourage patients to make better healthcare decisions. Many informatics interventions are aimed at improving health outcomes by influencing patient behavior. However, we know little about how the content of a message in these interventions can influence a health-related decision. In this research we formulate a conceptual model to help explain and guide the design of “persuasive messages”, those which can change and influence patient behavior. We apply the conceptual model to design persuasive appointment reminder messages using humancentered design principles. Finally, we empirically test our hypotheses in a randomized controlled trial in order to determine the effectiveness of persuasive appointment reminders to reduce the number of missed appointments in a sample of 1016 subjects in a community health center. The results of the study confirm that reminder messages are effective in reducing missed appointment compared with no reminders (p=0.028). Further, reminder messages that incorporate heuristic cues such as authority, commitment, liking, and scarcity are more effective than reminder messages without such cues (p=0.006). However, the addition of systematic arguments or reasons for attending appointments have no effect on appointment adherence (p=0.646). The results of this research suggest that the content of reminder messages may be an important factor in helping to reduce missed appointments.

Hepatocellular carcinoma survival in uninsured and underinsured patients.

BACKGROUND: The incidence of hepatitis C virus (HCV) and hepatocellular carcinoma (HCC) is increasing. The purpose of this study is to establish baseline survival in a medically-underserved population and to evaluate the effect of HCV seropositivity on our patient population. MATERIALS AND METHODS: We reviewed clinicopathologic parameters from a prospective tumor registry and medical records from the Harris County Hospital District (HCHD). Outcomes were compared using Kaplan-Meier survival analysis and log-rank tests. RESULTS: A total of 298 HCC patients were identified. The median survival for the entire cohort was 3.4 mo. There was no difference in survival between the HCV seropositive and the HCV seronegative groups (3.6 mo versus 2.6 mo, P = 0.7). Patients with a survival <1 mo had a significant increase in>αfetoprotein (AFP), international normalized ratio (INR), model for end-stage liver disease (MELD) score, and total bilirubin and decrease in albumin compared with patients with a survival ≥ 1 mo. CONCLUSIONS: Survival for HCC patients in the HCHD is extremely poor compared with an anticipated median survival of 7 mo reported in other studies. HCV seropositive patients have no survival advantage over HCV seronegative patients. Poorer liver function at diagnosis appears to be related to shorter survival. Further analysis into variables contributing to decreased survival is needed.

Outcomes of truncal vascular injuries in children.

BACKGROUND: Pediatric truncal vascular injuries occur infrequently and have a reported mortality rate of 30% to 50%. This report examines the demographics, mechanisms of injury, associated trauma, and outcome of patients presenting for the past 10 years at a single institution with truncal vascular injuries. METHODS: A retrospective review (1997-2006) of a pediatric trauma registry at a single institution was undertaken. RESULTS: Seventy-five truncal vascular injuries occurred in 57 patients (age, 12 +/- 3 years); the injury mechanisms were penetrating in 37%. Concomitant injuries occurred with 76%, 62%, and 43% of abdominal, thoracic, and neck vascular injuries, respectively. Nonvascular complications occurred more frequently in patients with abdominal vascular injuries who were hemodynamically unstable on presentation. All patients with thoracic vascular injuries presenting with hemodynamic instability died. In patients with neck vascular injuries, 1 of 2 patients who were hemodynamically unstable died, compared to 1 of 12 patients who died in those who presented hemodynamically stable. Overall survival was 75%. CONCLUSIONS: Survival and complications of pediatric truncal vascular injury are related to hemodynamic status at the time of presentation. Associated injuries are higher with trauma involving the abdomen.

Maternal and neonatal outcomes by labor onset type and gestational age.

OBJECTIVE: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. STUDY DESIGN: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. RESULTS: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor. CONCLUSION: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.

Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair.

BACKGROUND: Renal failure after thoracoabdominal aortic repair is a significant clinical problem. Distal aortic perfusion for organ and spinal cord protection requires cannulation of the left femoral artery. In 2006, we reported the finding that direct cannulation led to leg ischemia in some patients and was associated with increased renal failure. After this finding, we modified our perfusion technique to eliminate leg ischemia from cannulation. In this article, we present the effects of this change on postoperative renal function. METHODS: Between February 1991 and July 2008, we repaired 1464 thoracoabdominal aortic aneurysms. Distal aortic perfusion was used in 1088, and these were studied. Median patient age was 68 years, and 378 (35%) were women. In September 2006, we began to adopt a sidearm femoral cannulation technique that provides distal aortic perfusion while maintaining downstream flow to the leg. This was used in 167 patients (15%). We measured the joint effects of preoperative glomerular filtration rate (GFR) and cannulation technique on the highest postoperative creatinine level, postoperative renal failure, and death. Analysis was by multiple linear or logistic regression with interaction. RESULTS: The preoperative GFR was the strongest predictor of postoperative renal dysfunction and death. No significant main effects of sidearm cannulation were noted. For peak creatinine level and postoperative renal failure, however, strong interactions between preoperative GFR and sidearm cannulation were present, resulting in reductions of postoperative renal complications of 15% to 20% when GFR was <60 mL>/min/1.73 m(2). For normal GFR, the effect was negated or even reversed at very high levels of GFR. Mortality, although not significantly affected by sidearm cannulation, showed a similar trend to the renal outcomes. CONCLUSION: Use of sidearm cannulation is associated with a clinically important and highly statistically significant reduction in postoperative renal complications in patients with a low GFR. Reduced renal effect of skeletal muscle ischemia is the proposed mechanism. Effects among patients with good preoperative renal function are less clear. A randomized trial is needed.

Pancreatic adenocarcinoma in a patient with situs inversus: a case report of this rare coincidence.

BACKGROUND: Situs inversus (SI) is a relatively rare occurrence in patients with pancreatic adenocarcinoma. Pancreatic resection in these patients has rarely been described. CT scan imaging is a principle modality for detecting pancreatic cancer and its use in SI patients is seldom reported. CASE PRESENTATION: We report a 48 year old woman with SI who, despite normal CT scan 8 months earlier, presented with obstructive jaundice and a pancreatic head mass requiring a pancreaticoduodenectomy. The surgical pathology report demonstrated pancreatic adenocarcinoma. CONCLUSION: SI is a rare condition with concurrent pancreatic cancer being even rarer. Despite the rarity, pancreaticoduodenectomy in these patients for resectable lesions is safe as long as special consideration to the anatomy is taken. Additionally, radiographic imaging has significantly improved detection of early pancreatic cancer; however, there continues to be a need for improved detection of small neoplasms.

Patient satisfaction and nursing staff work satisfaction in an urban public teaching hospital

This study examined the level of patient satisfaction and nursing staff work satisfaction at an urban public hospital in the Southwestern United States. The primary objectives of this study were to determine: (1) the level of overall patient satisfaction and satisfaction with specific dimensions of hospital care; (2) the differences in patient satisfaction according to demographic characteristics (age, gender, ethnicity, and education completed) and predispositional factors (perceived health status, perceived level of pain, prior contact with the hospital, and hospital image) and the relative importance of each variable on patient satisfaction; (3) the level of overall work satisfaction and satisfaction with specific dimensions of work experienced by the medical/surgical nursing staff; (4) the differences in work satisfaction experienced by the nursing staff based on demographic variables (age, gender, ethnicity, and marital status) and professional factors (education completed, staff position, the number of years employed with the hospital, and number of years employed in nursing) and the relative importance of each variable on work satisfaction; and (5) to determine the effect of the nursing work milieu on patient and staff satisfaction.^ The study findings showed that patients experienced a moderate to low level of satisfaction with the dimensions of hospital care (admission process, daily care, information, nursing care, physician care, other hospital staff, living arrangements, and overall care). Of the eight dimensions of care, patients reported a relatively positive level of satisfaction (75 percent or better) with only one dimension: physician care. Ethnicity, perceived health status, and hospital image were significantly related to patient satisfaction. Hispanic patients, those who were in good health, and those who felt the hospital had a good image in their community were most satisfied with hospital care. Patients also reported areas of hospital care that needed the most improvement. Responses included: rude staff, better nursing care, and better communication.^ Findings from the nursing satisfaction survey indicated a low level of satisfaction with the dimensions of work (autonomy, pay, professional status, interaction, task requirements, and organizational policies). Only one dimension of work, professional status, received a mean satisfaction score in the positive range. Additionally, staff members were unanimously dissatisfied with their salaries. Frequently mentioned work-related problems reported by the staff included: staffing shortages, heavy patient loads. and excessive paperwork.^ The nursing milieu appeared to have had a significant effect on the satisfaction levels of patients nursing staff employees. The nursing staff were often short staffed, which increased the patient-to-nurse ratio. Consequently, patients did not receive the amount of attention and care they expected from the nursing staff. Crowded patient rooms allowed for little personal space and privacy. Dissatisfaction with living conditions served to influence patients' attitudes and satisfaction levels. These frustrations were often directed toward their primary caregivers, the nursing staff. Consequently, the nursing milieu appeared to directly affect and influence the satisfaction levels of both patients and staff. (Abstract shortened by UMI). ^

Outcomes assessment of a pediatric practice guideline

Objective. This study examines the structure, processes, and data necessary to assess the outcome variables, length of stay and total cost, for a pediatric practice guideline. The guideline was developed by a group of physicians and ancillary staff members representing the services that most commonly provide treatment for asthma patients at Texas Children's Hospital, as a means of standardizing care. Outcomes have needed to be assessed to determine the practice guideline's effectiveness.^ Data sources and study design. Data for the study were collected retrospectively from multiple hospital data bases and from inpatient chart reviews. All patients in this quasi-experimental study had a diagnosis of Asthma (ICD-9-CM Code 493.91) at the time of admission.^ The study examined data for 100 patients admitted between September 15, 1995 and November 15, 1995, whose physician had elected to apply the asthma practice guideline at the time of the patient's admission. The study examined data for 66 inpatients admitted between September 15, 1995 and November 15, 1995, whose physician elected not to apply the asthma practice guideline. The principal outcome variables were identified as "Length of Stay" and "Cost".^ Principal findings. The mean length of stay for the group in which the practice guideline was applied was 2.3 days, and 3.1 days for the comparison group, who did not receive care directed by the practice guideline. The difference was statistically significant (p value = 0.008). There was not a demonstrable difference in risk factors, health status, or quality of care between the groups. Although not showing statistical significance in the univariate analysis, private insurance showed a significant difference in the logistic regression model presenting an elevated odds ratio (odds ratio = 2.2 for a hospital stay $\le$2 days to an odds ratio = 4.7 for a hospital stay $\le$3 days) showing that patients with private insurance experienced greater risk of a shorter hospital stay than the patients with public insurance in each of the logistic regression models. Public insurance included; Medicaid, Medicare, and charity cases. Private insurance included; private insurance policies whether group, individual, or managed care. The cost of an admission was significantly less for the group in which the practice guideline was applied, with a mean difference between the two groups of $1307 per patient.^ Conclusion. The implementation and utilization of a pediatric practice guideline for asthma inpatients at Texas Children's Hospital has a significant impact in terms of reducing the total cost of the hospital stay and length of the hospital stay for asthma patients admitted to Texas Children's Hospital. ^