Predictors of repeat hospitalizations in children with asthma: the role of psychosocial and socioenvironmental factors

Development and initial validation of a pictorial quality of life measure for young children with asthma

OBJECTIVE

To develop and assess the psychometric properties of a pictorial version of the Pediatric Asthma Quality of Life Questionnaire (PAQLQ).

METHODS

A pictorial PAQLQ was administered to 101 children with mild to severe asthma between 5 and 7 years of age. A subgroup of 48 children followed longitudinally completed the established version of the PAQLQ.

RESULTS

A confirmatory factor analysis with modifications supported the factor structure of the established PAQLQ. The pictorial measure exhibited internal consistency reliability and convergent, discriminant, and predictive validity.

CONCLUSIONS

Results suggest that the pictorial version of the PAQLQ has an underlying factor structure that is similar to that of the established PAQLQ. Future research with larger and diverse samples is needed to confirm the factor structure of the pictorial PAQLQ.

Hospital readmissions for childhood asthma: the role of individual and neighborhood factors

OBJECTIVES

This study used a Cox proportional hazards model to determine whether neighborhood characteristics are associated with risk of readmission for childhood asthma independently of individual characteristics.

METHODS

Rhode Island Hospital Discharge Data from 2001 to 2005 were used to identify children younger than 19 years of age at the time of the index (i.e., first) asthma admission, defined as a primary diagnosis of asthma or a primary diagnosis of respiratory illness with a secondary or tertiary diagnosis of asthma (n=2,919). Hazard ratios of repeat hospitalizations for childhood asthma from 2001 to 2005 were estimated, controlling for individual- and neighborhood-level variables.

RESULTS

During the study period, 15% of the sample was readmitted for asthma (n=451). In the unadjusted cumulative hazard curves, children residing in the census tracts with the highest proportion of crowded housing conditions, racial minority residents, or neighborhood-level poverty had higher cumulative hospital readmission rates as compared with children who resided in less disadvantaged neighborhoods. In the fully adjusted models, children insured by Medicaid at the time of their index admission had readmission rates that were 33% higher than children who were privately insured.

CONCLUSION

Our findings suggest that differences in health-care coverage are associated with higher readmission rates for pediatric asthma, but the relationship between neighborhood inequality and repeat hospitalizations for pediatric asthma requires further exploration. Social indicators such as minority race, Medicaid health insurance, and neighborhood markers of economic disadvantage are tightly interwoven in the U.S. and teasing these relationships apart is important in asthma disparities research.

Latino caregivers' beliefs about asthma: causes, symptoms, and practices

BACKGROUND AND OBJECTIVE

This study examined belief systems of Latino caregivers who have children with asthma from Puerto Rican and Dominican backgrounds who resided on the Island of PR and the Mainland. The goal of this study was to document similarities and differences in beliefs about the causes, symptoms, and treatments of asthma across two sites and two Latino ethnic sub-groups of children who remain the most at risk for asthma morbidity.

METHODS

Participants included 100 primary caregivers of a child with asthma; 50 caregivers from Island PR and 50 caregivers from mainland RI were interviewed (at each site; 25 caregivers were from Puerto Rican backgrounds and 25 caregivers were from Dominican backgrounds). The interview included an assessment of demographic information and beliefs about the causes and symptoms of asthma and asthma practices.

RESULTS

Results indicated more similarities in beliefs about the causes and symptoms of asthma across site and ethnic group. The majority of differences were among beliefs about asthma practices by site and ethnic group. For example, a higher proportion of caregivers from Island PR, particularly those of Dominican descent, endorsed that a range of home and botanical remedies are effective for treating asthma.

CONCLUSIONS

Results from this study point to several interesting directions for future research including larger samples of Latino caregivers with children who have asthma. A discussion of the importance of understanding cultural beliefs about asthma and asthma practices is also reviewed.

Family climate of routine asthma care: associating perceived burden and mother-child interaction patterns to child well-being

This preliminary report links the literatures on family asthma management practices and on the characteristics of family interaction patterns thought to influence children's adjustment to a chronic physical illness. Specifically, this study of 60 families with a child with asthma examined the extent to which perceived burden of routine asthma care affected child mental health via its influence on parent-child interaction patterns. Mothers completed a measure of asthma management routine burden, mother and child were observed in a 15-minute interaction task, and children completed measures of child anxiety and asthma quality of life (QOL). Perceived routine burden significantly predicted child anxiety and QOL through its effect on mother-child rejection/criticism. The same pattern did not hold for mother intrusiveness/control. The results are discussed in terms of how overall family climate and regulation of routines affects child well-being. Implications for clinical practice and limitations of the study are provided.

The potential for reducing asthma disparities through improved family and social function and modified health behaviors

The National Workshop To Reduce Asthma Disparities assembled a multidisciplinary group comprised of scientists, clinicians, and community representatives to examine factors related to asthma disparities. Attention was given to the importance of discerning family, social, and behavioral factors that facilitate or impede the use of health-care services suitable to the medical status of an individual. This review highlights select biopsychosocial factors that contribute to these disparities, the manner in which they may contribute or protect persons affected by asthma, and recommended directions for future research.

Adolescents' psychosocial experiences living with asthma: a focus group study

INTRODUCTION

Asthma is influenced by and influences psychosocial experiences in adolescents. Therefore, the purpose of this study was to explore psychosocial experiences and coping strategies of a sample of adolescents with asthma based on their own accounts.

METHODS

Six focus group interviews were conducted in Central Virginia with 19 adolescents with asthma ages 12 to 18 years.

RESULTS

Three general descriptions of experiences with asthma were found in the data: "Doing less with more effort," "Missing out," and "Not all bad." Adolescents' negative emotions were compounded by perceptions of others' responses. Three coping strategies, "Toughening," "Guardedness," and "Modifying" also were identified.

DISCUSSION

Findings enhance understanding of particular patterns of psychosocial experiences in adolescents and lay a foundation for developmentally appropriate asthma interventions.

Family relational factors in pediatric depression and asthma: pathways of effect

OBJECTIVE

This study tested a multilevel biobehavioral family model proposing that negative family emotional climate contributes to child depressive symptoms, which in turn contribute to asthma disease severity. Parent-child relational insecurity is proposed as a mediator.

METHOD

Children with asthma (N = 112; ages 7-18; 55% male) reported relational security, anxiety, and depressive symptoms. Parent(s) reported demographics, asthma history and symptoms, and family emotional expression. Asthma diagnosis was confirmed by medical history provided by parent and child together, clinical evaluation, pulmonary function tests, and methacholine challenge, with disease severity categorized by National Heart, Lung, and Blood Institute guidelines. Medication adherence was measured prospectively.

RESULTS

Path analysis indicated a good fit of data to the hypothesized model (chi2 = 0.072, p =.97, normal fit index = 0.998, root mean square error of approximation = 0.000). Negative family emotional climate predicted child depressive symptoms (beta =.21, p < .04), which predicted asthma disease severity (beta =.35, p < .001), with relational insecurity a partial mediator (beta = -.23, p < .05, beta =.46, p < .001, respectively). Depression was associated with disease severity even after controlling for adherence (r p = 0.38, p < .05).

CONCLUSION

Findings are consistent with the proposed family model, suggesting the clinical importance of assessing and intervening in these specific family relational processes when treating children with depression and asthma.

Which family factors predict children's externalizing behaviors following discharge from psychiatric inpatient treatment?

OBJECTIVE

Parents' behavior management practices, parental stress, and family environment are highly pertinent to children's conduct problems. Preadolescents' psychiatric hospitalization usually arises because of severe conduct problems, so the relationships of family-related variables to postdischarge functioning warrant investigation. This study examined postdischarge clinical course and select family factors to model outcomes via a) predictors measured at admission, b) predictors measured concurrently with outcome, and c) changes in predictor values from admission through follow-up.

METHOD

In a prospective follow-up of 107 child psychiatry inpatients, caregivers completed rating scales pertaining to their child's behavior, parenting practices, parenting stress, caregiver strain, and their own psychological distress at admission and three, six, and 12 months after discharge.

RESULTS

The magnitude of reductions in parenting stress between admission and follow-up bore the strongest relationship to improvements in externalizing behavior. The largest and most sustained decreases in externalizing behavior arose among youngsters whose parents reported high parenting stress at admission and low parenting stress after discharge. By contrast, children whose parents reported low parenting stress at admission and follow-up showed significantly less postdischarge improvement. Parenting stress changes were not attributable to changes in behavioral symptoms. Parenting stress eclipsed relationships between behavior management practices and child outcomes, suggesting that parenting stress might have a mediational role.

CONCLUSIONS

High initial parenting stress disposed to better outcomes over the year of follow-up. Consistently low stress predicted less improvement. Higher stress at admission may imply more advantageous parent-child relationships or motivation for subsequent persistence with treatment. Interventions that ameliorate high stress may warrant further study. Low parenting stress might signify disengagement, or, alternatively, that parents of some chronically impaired children become rather inured to fluctuations in behavioral problems. If confirmed, further examination of these and other accounts for a relationship between low parenting stress and suboptimal child outcome seems warranted.

The association between childhood asthma and community violence, Los Angeles County, 2000

OBJECTIVE

This study's objective is to determine if there is an association between rates of violence and rates of childhood asthma in Los Angeles County communities.

METHODS

Rates of hospitalization for assault and for asthma were calculated for each ZIP Code and city in Los Angeles County. Linear regression was used to determine the effect of assault rates on asthma rates while controlling for potential confounders such as poverty and racial/ethnic distribution. At the city level, crime rates were included in the model as additional measures of community violence.

RESULTS

Hospitalization rates for childhood asthma and assaults were significantly correlated at both the city (r = 0.80) and the ZIP Code (r = 0.54) levels. The association remained significant when controlling for poverty and racial/ethnic distribution with linear regression (p < 0.0001). At the city level, the variables measuring the crime rate were not significant predictors of asthma hospitalizations.

CONCLUSIONS

Community violence as measured by the rate of assault hospi; talizations is associated with childhood asthma in Los Angeles County. Health care providers should consider their asthmatic patients' social environments when devising treatment plans.

Family processes in pediatric asthma

PURPOSE OF REVIEW

Family processes are best conceptualized within an integrated, dynamic biopsychosocial model of pediatric asthma. We reviewed the literature on specific family processes proposed to influence asthma outcomes, the mechanisms of influence, and family-focused interventions to improve asthma control.

RECENT FINDINGS

Family characteristics associated with asthma outcomes include caregiver psychological functioning, parenting, and whole-family processes. These characteristics influence asthma outcomes via asthma management behaviors and/or disease-related psychophysiologic pathways. Family-focused interventions designed to promote asthma control include psychoeducation and family therapy, although alternative models have also been proposed.

SUMMARY

Despite the increasing evidence that family processes contribute to asthma outcomes, few theory-based family interventions have been developed for children with asthma. Systemic consultation models and biobehavioral family interventions, in conjunction with pediatric care, appear to hold the most promise for helping families of children with poorly controlled asthma.

Disparities in asthma hospitalization in Massachusetts

OBJECTIVES

We examined racial disparities in asthma morbidity in Massachusetts.

METHODS

We used Massachusetts case-mix data from 1994 to 2002 to screen and track individual asthma morbidity and hospitalizations, which resulted in a sample of 10145 patients who were first hospitalized for asthma between 1997 and 2000. We followed these patients for 2 years after their first hospitalization. Because asthma is widely considered a preventable cause of hospitalization, we interpreted a readmission for asthma as an indication of failed asthma management.

RESULTS

We found substantial racial/ethnic disparities in readmission rates that persisted after control for comorbidities, payer type, and income. We estimated that the costs of repeat hospitalizations for asthma are in excess of one quarter of all asthma hospitalization costs.

CONCLUSION

Racial/ethnic disparities in asthma readmission rates show that Massachusetts is not on the frontier of asthma treatment.

Hospital readmission for bronchiolitis

The objectives of this study were to determine the rate and risk factors for hospital readmission after inpatient treatment for bronchiolitis. We conducted a retrospective cohort study from 2000 to 2002. The readmission rate within 30 days was 3.7% (95% Confidence Interval: 2.1%-6.0%). Readmission was not associated with age, prematurity, respiratory syncytial virus status, receipt of intensive care, or the observation period off supplemental oxygen. Those who required supplemental oxygen had a lower risk of readmission. Identifying children at risk for readmission is challenging. Children who did not require supplemental oxygen may be at greater risk because they are progressing in their illness.

The relationship of psychologic stress with childhood asthma

The psychologic influence on childhood asthma has long been a subject of investigation and controversy. This article illustrates the evidence that psychologic stress is related to children with asthma. Individual experience, the impact of family and neighborhood, the effect of caregiver mental status, and the presence of negative psychologic events affect symptoms and management. The pathways through which these factors influence asthma are mediated through cognitive and biologic mechanisms, with evidence indicating changes in behavior and alteration in immune response as underlying mechanisms. Psychologic issues are important in the patient with severe asthma. The mind-body paradigm that links psychologic stress to disease is necessary when considering the global evaluation of childhood asthma.

Risk Factors for Readmission After Neonatal Cardiac Surgery

BACKGROUND

Repeat hospitalizations place a significant burden on health care resources. Factors predisposing infants to unplanned hospital readmission after congenital heart surgery are unknown.

METHODS

This is a single-center, case-control study. Cases were rehospitalized or died within 30 days of discharge following an arterial switch operation (ASO) or Norwood procedure (NP) between 1992 and 2002. Controls underwent an ASO or NP between 1992 and 2002, and were neither readmitted nor died within 30 days of discharge. Patients and controls were matched by gender, year of birth, and procedure. Potential risk factors examined included indices of medical status at the time of discharge, determinants of access to health care, and provider characteristics.

RESULTS

Forty-eight patients were readmitted; 19 of 498 (3.8%) following an ASO and 29 of 254 (11.4%) after a NP (p < 0.001). Six infants died within 30 days of discharge; 1 after an ASO and 5 after a NP. In multivariate analysis, predictors of readmission or death were: residual hemodynamic problem(s) (odds ratio [OR] 4.10 [1.18, 14.3], p = 0.026); an intensive care unit stay greater than 7 days (OR 5.17 [1.12, 23.9] p = 0.035) (ASO); residual hemodynamic problem(s) (OR 5.84 [1.98, 17.2], p = 0.001); and establishment of full oral intake less than 2 days before discharge (OR 5.83 [1.83, 18.6], p = 0.003) (NP). Combining both groups, living in a low income Zip Code (< 30,000 dollars/annum) was associated with a lower likelihood of readmission (OR 0.25 [0.07, 0.85], p = 0.027).

CONCLUSIONS

Residual hemodynamic problem(s) predispose to hospital readmission after the ASO and NP. Low socioeconomic status may reduce the likelihood of readmission even when problems arise.

Symptom, family, and service predictors of children's psychiatric rehospitalization within one year of discharge

OBJECTIVE

To investigate predictors of readmission to inpatient psychiatric treatment for children aged 5 to 12 discharged from acute-care hospitalization.

METHOD

One hundred nine children were followed for 1 year after discharge from inpatient care. Time to rehospitalization was the outcome of interest. Predictors of readmission, examined via the Cox proportional hazards model, were symptom and family factors assessed at admission, aspects of psychiatric treatment, and demographic variables.

RESULTS

The Kaplan-Meier rehospitalization risk within 1 year of discharge, taking into account known readmissions and censored observations, was 0.37. Most readmissions (81%) occurred within 90 days of discharge. Four variables contributed simultaneously to predicting readmission risk. More severe conduct problems, harsh parental discipline, and disengaged parent-child relations conferred a higher risk for rehospitalization; these risks were attenuated when parents disclosed higher stress in their parenting roles.

CONCLUSIONS

Findings showed that psychiatric rehospitalization of children is common, most likely in the trimester after discharge, and highly related to both child symptoms and family factors measurable at admission. Results suggest that efforts to improve postdischarge outcomes of children should target the initial period following inpatient care, address vigorously the complex treatment needs of those with severe conduct problems, and aim to improve parent-child relations.

Hospital readmissions for childhood asthma: a 10-year metropolitan study

Studies of asthma admissions in the St. Louis metropolitan area have disclosed substantial numbers of children with readmissions. To determine the magnitude of readmissions and attributes of children with readmissions, a retrospective analysis of 8,761 children with 14,905 asthma hospitalizations for January 1, 1990 through December 31, 1999 at the two university affiliated children's hospitals in St. Louis was undertaken. Patient attributes of age, sex, race/ethnicity, residence, payor status, length of stay, and month of admission were compared between patients admitted once during that period and patients admitted multiple times. Main outcome measures were the total number of admissions and time to readmission during the study interval. A Lin, Wei, Yang, and Ying model of time to readmission showed that African-American children with Medicaid or no insurance are at higher risk of readmission (risk ratio 1.28) than are African-American patients with commercial insurance or white/other race/ethnicity patients regardless of insurance. Probability of readmission increased from 30% after a first admission, 46% after a second, and 59% after a third. Prior admission was a more specific indicator of readmission with greater positive predictive value than ethnicity or insurance status or their combination.