Socioeconomic variation in asthma hospitalization: excess utilization or greater need?

Applying epidemiologic concepts of primary, secondary, and tertiary prevention to the elimination of racial disparities in asthma

Despite medical and scientific advances, racial and ethnic disparities persist in US asthma morbidity and mortality rates. Progress in the elimination of these disparities will involve disentangling the contribution of social constructs, such as race, socioeconomic status, and culture, from that of the physical environment and genetic susceptibility. One approach to reducing asthma disparities is through the traditional disease prevention stages of intervention. As such, primary prevention targets reductions in asthma incidence; secondary prevention is the mitigation of established disease and involves disease detection, management, and control; and tertiary prevention is the reduction of complications caused by severe disease. Once causative factors at each level of disease prevention are understood, this knowledge can be translated into clinical practice and public health policy.

Improved asthma care after enrollment in the State Children's Health Insurance Program in New York

BACKGROUND

Uninsured children with asthma are known to face barriers to asthma care, but little is known about the impact of health insurance on asthma care.

OBJECTIVES

We sought to assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with asthma.

DESIGN

Parents of a stratified random sample of new enrollees in New York's SCHIP were interviewed by telephone shortly after enrollment (baseline, n = 2644 [74% of eligible children]) and 1 year later (follow-up, n = 2310 [87%]). Asthma was defined by parent report using questions based on National Heart, Lung, and Blood Institute criteria. A comparison group (n = 401) who enrolled in SCHIP 1 year later was interviewed as a test for secular trends.

MAIN OUTCOME MEASURES

Access (having a usual source of care [USC], unmet health needs, problems receiving acute asthma care), asthma-related medical visits, quality (continuity of care at the USC, problems receiving chronic asthma care, use of antiinflammatory medications), and asthma outcomes (change in asthma care or severity) were the main outcome measures used. Bivariate and multivariate analyses compared measures at baseline (year before SCHIP) versus follow-up (year during SCHIP).

RESULTS

Three-hundred eighty-three children (14%) had asthma at baseline, and 364 had asthma at follow-up (16%). No secular trends were detected between the baseline study group and the comparison group. After enrollment in SCHIP, improvements were noted in access: lacking a USC (decrease from 5% to 1%), unmet health needs (48% to 21%), and problems getting to the USC for asthma (13 to 4%). Children had fewer asthma-related attacks and medical visits after SCHIP (mean number of attacks: 9.5 to 3.8: mean number of asthma visits: 3.0 to 1.5; hospitalizations: 11% to 3%). Quality of asthma care improved for general measures (most/all visits to USC: 53% to 94%; mean rating of provider: 7.9 to 8.8 of 10) and asthma-specific measures (problems getting to the USC for asthma care when child was well: 13% to 1%). More than two thirds of the parents at follow-up reported that both quality of asthma care and asthma severity were "better or much better" than at baseline, generally because of insurance coverage or lower costs of medications and medical care.

CONCLUSIONS

Enrollment in New York's SCHIP was associated with improvements in access to asthma care, quality of asthma care, and asthma-specific outcomes. These findings suggest that health insurance improves the health of children with asthma.

Adequacy of outpatient management of asthma patients admitted to a state hospital in Argentina

OBJECTIVE

The aim of this study was to assess chronic outpatient management of adult patients admitted with asthma.

METHODOLOGY

A cross-sectional survey was conducted of 98 consecutive asthma admissions to a specialized pulmonary State Hospital in Buenos Aires, Argentina, over a 12-month period. Patients were surveyed, within 48 h of admission, with a previously validated questionnaire which deals with chronic outpatient management and measures taken by patients or physicians to treat symptoms during asthma exacerbations.

RESULTS

FEV1% predicted was 30.2 +/- 10.7. Mean admission rate and emergency department (ED) visits in the previous year were 0.7 +/- 1.2 and 4.6 +/- 5.1, respectively. A total of 96, 65 and 9% of the patients had been treated previously in the ED, admitted to hospital or mechanically ventilated, respectively. Only 62% had been prescribed inhaled corticosteroids (IC) by their physician; 38% had been prescribed nebulized beta agonists (Nbeta2) and 68% a metered dose inhaler (MDIbeta2). Inhaled beta2-agonist usage during acute exacerbations over the 24 h prior to admission was 14.4 +/- 7.4 puffs for MDIbeta2 and 8.6 +/- 5.4 occasions for Nbeta2. Only 11% of the patients were able to perform all the steps of the MDI inhalation technique correctly. An action plan had been provided by their physicians to 43% of patients, while 58% changed their medication on their own. Only three patients had a peak flow meter (PFM) prescribed. ED was used by 26% for their routine care. No health insurance coverage was available to 75.5% of the patients.

CONCLUSIONS

Underuse of IC, poor MDI inhalation technique, and low prescription of an action plan was common and a PFM was seldom prescribed. During exacerbations, many patients changed their medication spontaneously and MDIbeta2 underuse was observed.

Risk factors for asthma and asthma severity in nonurban children in Connecticut

STUDY OBJECTIVE

To examine asthma diagnosis, asthma severity, and the presence of established asthma risk factors in children who reside in nonurban communities.

DESIGN

A cross-sectional study was conducted of 19,076 children (6 months to 18 years of age) who lived in 146 nonurban communities in the greater Hartford, CT, region and who were enrolled in a disease-management program (Easy Breathing II; Michelle Cloutier, MD; Hartford, CT) designed to improve asthma diagnosis and treatment.

RESULTS

The overall frequency of physician-confirmed asthma in children seeking health care was 18%. Asthma frequency was related to low socioeconomic status (SES), non-Caucasian ethnicity, male gender, age > or = 5 years, and exposure to tobacco smoke, dust, or cockroaches in the multivariate analysis. When controlling for SES, African-American children were 1.33 times more likely (95% confidence interval [CI], 1.15 to 1.53) and Hispanic children were 1.60 times as likely (95% CI, 1.38 to 1.85) as Caucasian children to have asthma. In contrast, asthma severity was related to dust exposure, a family history of asthma, non-Caucasian ethnicity, and age < or = 4 years in the multivariate analysis. African-American children (odds ratio, 1.31; 95% CI, 1.03 to 1.67) had more severe asthma diagnosed as compared to Caucasian children. Hispanic ethnicity was not associated with an increase in asthma severity.

CONCLUSION

Risk factors for asthma in nonurban children are similar to risk factors in urban children. Ethnicity is a risk factor for asthma regardless of SES. Even in nonurban environments, African-American and Hispanic children have more asthma, and African-American children have more severe disease than their Caucasian counterparts.

Characteristics of Families That Complain Following Pediatric Emergency Visits

OBJECTIVE

The voicing of unsolicited observations by patients and families is a form of participation in the health care system. We investigated whether visits by patients of different race/ethnicities were equally represented in unsolicited complaints filed with a medical center's Office of Patient Affairs (OPA) regarding pediatric emergency visits.

METHODS

We conducted a population-based retrospective study, including pediatric emergency visits, at a large academic medical center between January 1999 and December 2002. We identified complaints to the OPA and conducted bivariate and multivariable analyses to determine whether patient race/ethnicity was associated with filing a complaint.

RESULTS

Among 105 322 total visits, the overall complaint rate was 1.22/1000 visits. Visits by white children had a complaint rate of 1.78/1000 visits compared with 0.37/1000 visits by African American children (P < .001). In multivariable analysis, visits by African American children remained less likely to be associated with a complaint to the OPA compared with visits by white children (adjusted odds ratio 0.30, 95% CI 0.17-0.55) after controlling for factors such as payer status.

CONCLUSIONS

Emergency-department visits by African American children were less likely to be associated with a complaint than visits by white children. Programs that use complaints in service recovery, quality assurance, and risk management efforts may unintentionally exclude segments of the patient population served by the institution.

Telemedicine reduces absence resulting from illness in urban child care: evaluation of an innovation

BACKGROUND

Common acute illness challenges everyone involved in child care. Impoverished inner-city families, whose children are most burdened by morbidity and whose reliance on child care is most important, are those least equipped to deal with this challenge.

OBJECTIVE

To assess the impact of telemedicine on absence from child care due to illness (ADI).

DESIGN/METHODS

A before-and-after design with historical and concurrent controls was used to study ADI in 5 inner-city child care centers in Rochester, New York, between January 1, 2001, and June 30, 2003. Enrollment averaged 138 children per center, of whom Medicaid covered 66%. Center 5 provided only concurrent controls. Telemedicine service began in the first 4 centers in a staggered fashion starting in May 2001. Baseline data on ADI before availability of telemedicine were collected in each center for a minimum of 18 weeks. The telemedicine model for diagnosis and treatment of common acute problems involved both real-time and store-and-forward information exchange between a child and telemedicine assistant in child care and an office-based telemedicine clinician. Devices used were an all-purpose digital camera (with attachments designed to facilitate capture of ear, nose, throat, skin, and eye images) and an electronic stethoscope. ADI indexed illness that had interrupted care and education for children and burdened both parents and the community with work loss and health care-related costs. Detailed attendance records and staff and parent interviews provided data. The total number of days of attendance expected from all registered children over the course of a week (total child-days) served as the denominator in calculating rates for ADI. The center-week served as the primary unit of analysis. This study is descriptive in character; statistics are not inferential but instead serve to summarize observations.

RESULTS

For the 400 weeks of valid observations contributed by the 5 centers, the mean ADI was 6.41 absences per 100 child-days per week. In bivariate analysis, predictors of ADI were children's mean age, child care center, proportion of children covered by Medicaid, season of the year, and availability of telemedicine. ADI during weeks with telemedicine (4.07 absences per 100 child-days) was less than half that during weeks without telemedicine (8.78 absences per 100 child-days). After adjusting for potentially confounding variables using the generalized estimating equations method, telemedicine remained the strongest predictor of ADI. A 63% reduction in ADI was attributable to telemedicine, an effect similar to the 59% variation in ADI with season of the year. During the 201 total weeks that telemedicine services were available, 940 telemedicine encounters occurred. Telemedicine clinicians for these 940 encounters recommended exclusion from child care for 7.0% and in-person visits for 2.8% of the children. In surveys, parents indicated that 91.2% of telemedicine contacts allowed them to stay at work and that 93.8% of problems managed by telemedicine would otherwise have led to an office or emergency department visit.

CONCLUSIONS

Telemedicine holds substantial potential to reduce the impact of illness on health and education of children, on time lost from work in parents, and on absenteeism in the economy.

Mortality of white Americans, African Americans, and Canadians: the causes and consequences for health of welfare state institutions and policies

The life expectancy of African Americans has been substantially lower than that of white Americans for as long as records are available. The life expectancy of all Americans has been lower than that of all Canadians since the beginning of the 20th century. Until the 1970s this disparity was the result of the low life expectancy of African Americans. Since then, the life expectancy of white Americans has not improved as much as that of all Canadians. This article discusses two issues: racial disparities in the United States, and the difference in life expectancy between all Canadians and white Americans. Each country's political culture and institutions have shaped these differences, especially national health insurance in Canada and its absence in the United States. The American welfare state has contributed to and explains these differences.

Air pollution and the demand for hospital services: a review

Time-series studies published since 1993 on the association between short-term changes in air quality and use of hospital services, including both inpatient and emergency room use, are reviewed. The use of nonparametric analysis, often incorporating generalized additive models (GAMs), has increased greatly since the early 1990s. There have also been three major multi-city studies, which together analyzed data from well over 100 cities in Europe and North America. Various air pollutants, especially ozone (O(3)), particulate matter (PM), nitrogen dioxide (NO(2)) and sulfur dioxide (SO(2)), were generally found to be significantly associated with increased use of hospital services. Ozone tends to have stronger effects in the summer during periods of higher concentrations. Several studies revealed synergistic effects between pollutants such as PM and SO(2). Overall, short-term exposure to air pollutants is found to be an important predictor of increased hospital and emergency room use around the world.

Residential exposure to volatile organic compounds and asthma

We critically analysed the literature concerning exposure to volatile organic compounds and asthma. Observational studies have consistently found a relation between volatile organic compounds and indicators of asthma, such as symptoms, peak flows, and objectively measured bronchial reactivity. In contrast, interventional studies have generally failed to find a relation between exposure to residential levels of formaldehyde and other volatile organic compounds and asthma. One hypothesis to explain the discrepancy in findings between interventional and observational studies is that the effect size is small requiring relatively large numbers of study subjects, common in observational studies but often not feasible in interventional studies. Another hypothesis is that longer duration of exposure is important, a common circumstance in observational studies where the home environment is the exposure setting. In contrast, duration of exposure in interventional studies is usually of minutes-to-hours in a chamber. Finally, the observed association in observational studies could be confounded by a factor which is a determinant of asthma and is also associated with exposure to volatile organic compounds.

Ecological measures of socioeconomic status and hospital readmissions for asthma among Canadian adults

BACKGROUND

Lack of an association between area-based socioeconomic status (SES) and readmission for asthma was investigated in a country with a universal health care system.

METHODS

Data linkage analysis was conducted based on hospitalization data from Statistics Canada's Person-oriented Information Database and area-based SES data from the 1996 Census. Hospital records for 8333 asthma patients aged 20-64 years in all Canadian provinces except Quebec who were admitted in 1995/1996 were linked to determine the number of patients who were rehospitalized within the same fiscal year. The area-based SES of the patients was defined according to the average personal income and proportion of residents with a university degree in an enumeration area (EA). Incidence rates of readmission for asthma were calculated based on the total years at risk. Cox's proportional hazard model was used to adjust for age, sex, province, and length of stay for first admission.

RESULTS

The incidence rate of asthma rehospitalization was 31.6 per 100 person-years for men and 37.2 per 100 person-years for women. Neither average EA income or education level was significantly associated with rehospitalization for asthma. Women living in poor areas tended to have an increased incidence of asthma rehospitalization, but the difference was not significant after adjustment for covariates using the Cox regression model.

CONCLUSION

Socioeconomic status measured at the neighborhood level has no significant impact on rehospitalization for asthma among Canadian adults.

Characteristics and outcome for admissions to adult, general critical care units with acute severe asthma: a secondary analysis of the ICNARC Case Mix Programme Database

INTRODUCTION

This report describes the case mix, outcome and activity (duration of intensive care unit [ICU] and hospital stay, inter-hospital transfer, and readmissions to the ICU) for admissions to ICUs for acute severe asthma, and investigates the effect of case mix factors on outcome.

METHODS

We conducted a secondary analysis of data from a high-quality clinical database (the Intensive Care National Audit and Research Centre [ICNARC] Case Mix Programme Database) of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland over the period 1995-2001.

RESULTS

Asthma accounted for 2152 (1.7%) admissions, and in 57% mechanical ventilation was employed during the first 24 hours in the ICU. A total of 147 (7.1%) patients died in intensive care and 199 (9.8%) died before discharge from hospital. The mean age was 43.6 years, and the ratio of women to men was 2:1. Median length of stay was 1.5 days in the ICU and 8 days in hospital. Older age, female sex, having received cardiopulmonary resuscitation (CPR) within 24 hours before admission, having suffered a neurological insult during the first 24 hours in the ICU, higher heart rate, and hypercapnia were associated with greater risk for in-hospital death after adjusting for Acute Physiology and Chronic Health Evaluation II score. CPR before admission, neurological insult, hypoxaemia and hypercapnia were associated with receipt of mechanical ventilation after adjusting for Acute Physiology and Chronic Health Evaluation II score.

CONCLUSION

ICU admission for asthma is relatively uncommon but remains associated with appreciable in-hospital mortality. The greatest determinant of poor hospital survival in asthma patients was receipt of CPR within 24 hours before admission to ICU. Clinical management of these patients should be directed at preventing cardiac arrest before admission.

Race/ethnicity and asthma among children presenting to the emergency department: differences in disease severity and management

OBJECTIVE

To investigate racial/ethnic differences in acute asthma among children who present to the emergency department (ED).

METHOD

We analyzed data from 2 prospective cohort studies performed during 1997-1998 as part of the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers at 40 EDs in 18 US states provided 24-hour-per-day coverage for a median of 2 weeks per year. Children with acute asthma were interviewed in the ED and by telephone 2 weeks after discharge.

RESULTS

Among 1095 patients, 679 (62%) were black, 256 (23%) were Hispanic, and 160 (15%) were white. Black and Hispanic children had greater histories of lifetime (63%, 64%, 46%) and past-year (34%, 31%, 14%) hospitalization and more ED visits in the past year (medians: 2, 3, 1). Asthma severity at ED presentation, ED management and course, hospitalization during the index visit, discharge prescriptions, and postdischarge outcomes were equivalent among all race/ethnic groups.

CONCLUSION

Despite pronounced race/ethnicity-based differences in chronic asthma, all racial/ethnic groups exhibited similar acute asthma severity, ED management, and course. However, given that black and Hispanic children exhibited much higher admission histories and past ED use, the equivalence in inhaled corticosteroid prescriptions on discharge is a disconcerting pattern that mirrors previous literature on outpatient prescription practices. In addition to barriers attributable to socioeconomic factors, health care providers and policy makers should target equalizing deficiencies in preventive medication prescription practices.

Insurance and quality of care for adults with acute asthma

OBJECTIVE

The relationship between health care insurance and quality of medical care remains incompletely studied. We sought to determine whether type of patient insurance is related to quality of care and subsequent outcomes for patients who arrive in the emergency department (ED) for acute asthma.

DESIGN

Using prospectively collected data from the Multicenter Airway Research Collaboration, we compared measures of quality of pre-ED care, acute severity, and short-term outcomes across 4 insurance categories: managed care, indemnity, Medicaid, and uninsured.

SETTING AND PARTICIPANTS

Emergency departments at 57 academic medical centers enrolled 1,019 adults with acute asthma.

RESULTS

Patients with managed care ranked first and uninsured patients ranked last on all 7 unadjusted quality measures. After controlling for covariates, uninsured patients had significantly lower quality of care than indemnity patients for 5 of 7 measures and had lower initial peak expiratory flow rates than indemnity insured patients. Patients with managed care insurance were more likely than indemnity-insured patients to identify a primary care physician and report using inhaled steroids in the month prior to arrival in the ED. Patients with Medicaid insurance were more likely than indemnity-insured patients to use the ED as their usual source of care for problems with asthma. We found no differences in patient outcomes among the insurance categories we studied.

CONCLUSIONS

Uninsured patients had consistently poorer quality of care and than insured patients. Despite differences in indicators of quality of care between types of insurance, we found no differences in short-term patient outcomes by type of insurance.

Childhood asthma in an urban community: prevalence, care system, and treatment

OBJECTIVES

We describe the system of asthma care in Hartford, CT, an urban, minority community.

METHODS

The health field concept was used to organize factors influencing asthma prevalence and severity. Data were obtained from national, state, and municipal reports, and from surveys of children in Hartford seeking medical care in an asthma program called Easy Breathing.

RESULTS

Between June 1, 1998, and May 1, 2000, 21% of children receiving Medicaid in Hartford did not file a medical claim. Between 1998 and 2000, the number of providers in Hartford decreased by 37% while the number of outpatient visits increased by 8%. Using claims data, we found the following: 19.0% of Hartford children had asthma (data from the International Classification of Disease, ninth revision, and the National Drug Code); and 12% of children with asthma filled a prescription for inhaled corticosteroid therapy, 83% for a bronchodilator, and 36% for an oral corticosteroid. Children with asthma were more likely to be hospitalized (10% vs 5%, respectively) and to visit an emergency department (45% vs 29%, respectively), and, on average, they had more hospital days (0.603 vs 0.415 days per child, respectively) and more outpatient visits per year (4.7 vs 2.5 visits, respectively) compared to children without asthma. Asthma prevalence in the 6,643 children surveyed in the Easy Breathing program was 41%. Persistent asthma was diagnosed in 50% of the children with asthma. Asthma prevalence varied by ethnic origin, age, and gender, and was highest in Hispanic/Puerto Rican children, in children 5 to 10 years of age, in boys up to 10 years of age, and in girls after 15 years of age.

CONCLUSION

Improved personal behaviors and medical care will have a limited sustained impact on childhood asthma until basic environmental issues are modified. The health field concept provides a mechanism with which to address the issues surrounding asthma in urban communities.

Socioeconomic status and utilization of health care services among asthmatic children

We evaluated the relation between socioeconomic factors and hospitalization as well as emergency department (ED) visits among asthmatic children who had universal access to health care. Newly diagnosed asthmatic children 3-4 years of age were followed up for a period of 6 years. Information on hospitalization and ED visits was obtained by interviewing parents. Socioeconomic status (SES) was measured by paternal occupation, race, type of dwelling, and an index of crowding. After adjusting for asthma severity, logistic regression analysis showed that children with fathers in the economically least advantaged occupations were more likely to be hospitalized due to their asthma [father's occupation group 3 (FOG3), odds ratio (OR)=2.1, 95% confidence interval (95% CI)=0.2-19.8; father's occupation group 4 (FOG4), OR=13.9, 95% CI=1.1-181.4]. The probability of emergency department visits was not significantly different according to the studied variables. Emergency department visits were not influenced by SES variables, probably due to the absence offinancial barriers to access health care. However, SES differences in hospitalization may suggest differential management and/or treatment practices according to socioeconomic status at the emergency departments.

Regional differences in hospitalizations for asthma in the United States, 1988-1996

Hospitalization rates for asthma are higher in the Northeast United States than in other regions, despite similar regional prevalence rates. Whether these higher rates reflect differences in asthma presentation or severity or else general differences in hospitalizations is unclear. We examined regional differences in asthma hospitalizations for the United States from 1988 through 1996 using data from the National Hospital Discharge Survey. We classified asthma hospitalizations into those in which asthma was either the primary diagnosis or any listed diagnosis. From 1988 through 1996, the rate of hospitalizations for asthma as the primary diagnosis, per 10,000 population, increased in the Northeast, but declined in other regions. By 1996, these rates were 24.5 in the Northeast, 18.4 in the Midwest, 15.8 in the South, and 14.2 in the West. The Northeast also had the highest absolute rate and the highest rate of increase for asthma as any listed diagnosis during the study period. These higher rates of asthma hospitalizations in the Northeast occurred despite a 9.3% decline in the age-adjusted rate for all hospitalizations in the region. These results indicate a greater rate of hospitalization for asthma in the Northeast than in other regions, suggesting that asthma there may be more severe.

Symptom monitoring in childhood asthma: a randomized clinical trial comparing peak expiratory flow rate with symptom monitoring

BACKGROUND

Accurate symptom evaluation is a critical component of asthma management. Limited data are available about the accuracy of symptom evaluation by children with asthma and their parents, or the impact of various symptom-monitoring strategies on asthma morbidity outcomes.

OBJECTIVE

The purpose of this randomized clinical trial was to evaluate the effect of three different intensities of symptom monitoring on asthma morbidity outcomes.

METHODS

One hundred sixty-eight children (ages 6 to 19) of diverse racial, geographic, and socioeconomic backgrounds were randomized to 1 of 3 treatment groups (subjective symptom evaluation, symptom-time peak expiratory flow rate (PEFR) monitoring, daily PEFR monitoring) in this longitudinal, clinical trial. Outcome measures included a summary asthma severity score, forced expiratory volume in 1 second, symptom days, and health care utilization.

RESULTS

Children who used PEFR meters (PFMs) when symptomatic had a lower asthma severity score, fewer symptom days, and less health care utilization than children in the other two treatment groups. Minority and poor children had the greatest amount of improvement using PFMs when symptomatic. Results were much less striking in white families. Thirty percent of families in the PFM treatment groups discontinued use entirely by 1 year postexit, whereas the majority of families who continued use (94%) used them only when symptomatic to inform symptom interpretation and management decisions.

CONCLUSIONS

Not every child with asthma needs a PFM. Children and families facing extra challenges as a result of illness severity, sociodemographic, or health care system characteristics clearly benefited most from PFM use.

Preferential prescribing of oral corticosteroids in Irish male asthmatic children

AIMS

To determine if there is a gender difference in the prescription of oral corticosteroids in asthmatic children (< 15 years).

METHODS

8072 asthmatics were identified on the basis that they received a prescription for either an inhaled beta-adrenoceptor agonist, an inhaled corticosteroid, inhaled cromoglycate/nedocromil sodium, oral xanthines or leukotriene antagonist. Odds ratios (OR) and 95% confidence intervals (CI) were determined for the different asthma treatments for males compared with females.

RESULTS AND CONCLUSIONS

Male asthmatic children were more likely (OR = 1.37, 95% CI = 1.21,1.55, P < 0.001) to receive a prescription for an oral corticosteroid compared with their female counterparts suggesting a possible increased severity of their condition, rather than a different management of their disease. Male asthmatic children were less likely to be prescribed an antibiotic over the study period (OR = 0.85, 95% CI = 0.77, 0.93, P < 0.001).

School readiness among urban children with asthma

BACKGROUND

Children with chronic illnesses, including asthma, are at risk for school problems. Developmental problems, however, may begin before school entry, and the developmental status of preschool children with asthma has not been evaluated.

OBJECTIVE

To test the hypothesis that urban preschool children with asthma have lower parent-reported developmental scores compared with children without asthma.

METHODS

A comprehensive survey of children beginning kindergarten in 1998 in the urban school system in Rochester, NY, collected parent reports of demographic, medical, and developmental data. We compared children with asthma with and without limitation of activity to children without asthma for motor, language, socioemotional, and school readiness skills and the need for extra help with learning. Linear and logistic regression were used to determine associations between asthma and developmental outcomes.

RESULTS

Among the 1058 children in this sample, 9% had asthma, including 5% with asthma with limitation of activity. After adjustment for multiple potential confounding variables, the children with asthma with limitation had lower scores on school readiness skills compared with children without asthma (2.0 vs 2.5, P <.001). Further, the parents of children with asthma with limitation were substantially more likely (P <.05) to describe them as needing extra help with learning (74% vs 56%; odds ratio, 3.2; 95% confidence interval, 1.5--7.8).

CONCLUSIONS

Urban preschool children with significant asthma had poorer parent-reported school readiness skills and a greater need for extra help with learning compared with children without asthma. This finding suggests that developmental problems for children with asthma may begin before school entry.

The use of anti-asthmatic drugs in children: results of a community-based survey in Germany

PURPOSE

To describe the use of anti-asthma drugs in children in the general population and in children with asthma using data from two large surveys in Germany.

METHODS

Community-based random sample of 5-7 and 9-11-year-old children in Dresden and Munich were studied in 1995/96 by parental questionnaires using the Phase II protocol of the International Study of Asthma and Allergies in Childhood (ISAAC). A total of 11,094 children participated in the surveys (response rate 83%).

RESULTS

In all children, inhaled beta 2-agonists were used most frequently during the last 12 months (2.6%), followed by inhaled cromolyns (2.5%), oral beta 2-agonists (1.5%), and inhaled steroids (0.9%). Drug use was significantly higher among boys than girls and in older children compared to younger ones (P < 0.05 for both). Among children with current asthma, 47% had used inhaled beta 2-agonists, 43% inhaled cromolyns, 22% oral beta 2-agonists, and 16% inhaled steroids. Inhaled steroids were used significantly more often in Dresden (21.7%) than in Munich (11.2%) (P < 0.05).

CONCLUSIONS

Among anti-asthma drugs, agents used for symptomatic relief were the most frequently reported followed by inhaled anti-inflammatory agents. Most of the anti-inflammatory drugs used were SCG, which may indicate under-treatment with inhaled steroids.

Asthma and the risk of hospitalization in Canada : the role of socioeconomic and demographic factors

OBJECTIVE

Asthma is an important determinant of hospitalization. The study aims to examine the modifying effects of demographic and socioeconomic factors on the relationship between asthma and the overall number of hospitalizations.

METHODS

We examined the data on 17,601 Canadians who were > or = 12 years of age to explore the combined effects of asthma and other factors on hospitalization within the context of a publicly funded health-care system. Asthma was determined by an affirmative response to the question: "Do you have asthma diagnosed by a health professional?" The subjects also were asked whether they had been an overnight patient in a hospital during the past 12 months.

RESULTS

Asthma as a risk factor explained 3.7% of all hospitalizations of men and 2.4% of all hospitalizations of women. Overall, hospitalization was positively associated with female gender, old age, and low household income. The odds ratio for asthma as a risk factor for overall hospitalization (ie, hospitalization for any reason and all causes, not only for asthma) was greater for younger men than for older men, for less-educated women than for well-educated women, and for men with middle or high incomes than for men with low incomes.

CONCLUSIONS

These results suggest that demographic and socioeconomic factors play a role in the relationship between asthma and the overall number of hospitalizations, with certain population subgroups being at greater risk of hospitalization in relation to asthma.

A community-based study of near-fatal asthma

BACKGROUND

The purpose of this study was to describe the community-based impact of near-fatal asthma within the District of Columbia (Washington, DC).

METHODS

The design was a prospective cohort study. Subjects included all persons in 1993 who presented to Washington, DC hospitals alive, requiring intubation for respiratory failure (including subjects who subsequently died in the hospital). Washington, DC hospitals were contacted on a biweekly basis to identify subjects. Patients were contacted by mail, followed by an interview with the subject or proxy.

RESULTS

Of the 35 case subjects identified, 31 (88.6%) were interviewed. Sixty-one percent of the subjects were female; 84% were African-American; and 45.2% were less than 18 years old. Forty-five percent had asthma for 10 or more years. Twenty-three percent reported the emergency department as their usual source of health care, and 32% saw a provider on a weekly basis. Fifty-two percent were taking four or more prescription medications, and 29% were taking no anti-inflammatory medications. In the 24 hours before the event, 77% reported difficulty breathing, but only 64% reported contacting a health care provider.

CONCLUSIONS

Community-based investigation of near-fatal asthma may lead to a better characterization of risk factors associated with this event. Findings from this study suggest that some of the factors associated with near-fatal events may be different from those associated with fatal asthma and that up to one third of the events may have been preventable.

Well child care in the United States: racial differences in compliance with guidelines

OBJECTIVES

This study sought to estimate the rate of compliance with American Academy of Pediatrics guidelines for well child care in the first 6 months of life and to determine risks for inadequate care.

METHODS

The study included 7776 infants whose mothers participated in both the 1988 National Maternal and Infant Health Survey and its 1991 longitudinal follow-up and whose mothers or pediatric providers supplied information about their medical care. Regression analysis was used to determine the probability of incomplete compliance with guidelines for well child care in relation to several socioeconomic risks.

RESULTS

Fifty-eight percent of White infants, 35% of African American infants, and 37% of Hispanic infants obtained all recommended well child care. African American race was the biggest risk for inadequate care (odds ratio = 1.7, 95% confidence interval = 1.5, 1.9), followed by low levels of maternal education, low income, and poor prenatal care. The risk for African American infants persisted across socioeconomic levels.

CONCLUSIONS

The racial disparities identified suggest that cultural barriers to seeking preventive care need further study and that programs aimed at reducing these barriers need to be developed.

Epidemiology of asthma: the year in review

Asthma is a worldwide problem, with more than 17 million persons in the United States estimated to have asthma, and there is evidence that the prevalence is increasing. This article reviews the latest epidemiologic evidence for an increase in asthma prevalence and morbidity, and the evidence that environment plays a significant role in this disease. This review focuses on five specific areas: prevalence, incidence, natural history, environmental factors, and morbidity and mortality.