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Correa-Agudelo E, Ding L, Beck AF, Kahn RS, Mersha TB. Analyzing Racial Disparities in Pediatric Atopic Comorbidity Emergency Department Visitation Using Electronic Health Records. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2826-2837.e10. [PMID: 39029655 DOI: 10.1016/j.jaip.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 07/01/2024] [Accepted: 07/08/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Although atopic diseases and associated comorbidities are prevalent in children, little is known about racial differences in emergency department (ED) visitation. OBJECTIVE We sought to examine racial differences in ED visitation among children with allergic comorbidities. METHODS We conducted a retrospective study of patients (<21 years) who visited the ED at a large pediatric hospital for atopic dermatitis (AD), food allergy (FA), asthma, allergic rhinitis (AR), and eosinophilic esophagitis (EoE) from 2015 to 2019. We determined the probability of ED encounter-free survival time using hazard ratios (HRs) and time to recurrence (TTR) of ED encounter for patients identified as Black/African American (AA) and White/European American (EA). We assessed potentially underlying allergic, demographic, and place-based factors and potential interactions between factors. RESULTS A total of 30,894 patients (38% AA and 62% EA) had 83,078 ED encounters (38,378 first ED encounters and 44,700 recurrent ED encounters) during the study period. Asthma and AR showed the highest rate of comorbidity in ED encounters in both AA and EA children. AA children exhibited a higher HR for encounter following index AD and asthma encounters. We found an interaction between the type of insurance and race in ED encounters for AD, FA, AR, and EoE. In AA children, those insured by Medicaid demonstrated a higher HR for any encounter than those with commercial insurance. Conversely, in EA children, those with Medicaid insurance showed a lower HR than their commercially insured peers. Regardless of race, allergic comorbidity increased the HR of ED encounter (1.12-1.62) for all allergic diseases. At 5-year follow-up, mean differences in TTR were shorter in AA children than EA children in AD, FA, and asthma. CONCLUSIONS Identification of disease-specific racial disparities in ED visitation related to atopic diseases is a necessary first step toward the design and implementation of interventions capable of equitably reducing emergency care in atopic comorbid children.
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Affiliation(s)
- Esteban Correa-Agudelo
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew F Beck
- Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; Fisher Child Health Equity Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Office of Population Health, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert S Kahn
- Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; Fisher Child Health Equity Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tesfaye B Mersha
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Ou MC, Li CP, Chang HC, Gau SY. Racial disparities in pediatric atopic comorbidity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2881. [PMID: 39384273 DOI: 10.1016/j.jaip.2024.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 10/11/2024]
Affiliation(s)
- Ming-Che Ou
- Division of Hematology/Medical Oncology, Department of Medicine, Tungs' Taichung MetroHarbor Hospital, Taichung City, Taiwan
| | - Chen-Pi Li
- Department of Nursing & Tungs' Taichung MetroHarbor Hospital, Taichung City, Taiwan
| | - Hui-Chin Chang
- Evidence-based Medicine Center, Chung Shan Medical University Hospital, Taichung, Taiwan; Library, Chung Shan Medical University Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
| | - Shuo-Yan Gau
- Department and Graduate Institute of Business Administration, National Taiwan University, Taipei, Taiwan; Department of Pharmacology, Chung Shan Medical University, Taichung, Taiwan; Orthopedics Department, Chi-Mei Medical Center, Tainan, Taiwan
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Chen S, Zhang Y, Wei J, Hao C, Wu W, Li Z, Guo T, Lin Z, Zhang W, Hao Y. Risk of stroke admission after long-term exposure to PM 1: Evidence from a large cohort in South China. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2024; 283:116720. [PMID: 39053181 DOI: 10.1016/j.ecoenv.2024.116720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 07/04/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Limited attention has been paid to the health effects of long-term PM1 exposure on stroke admission. Current investigations exploring the long-term PM exposure effect are largely based on observational studies, and PM generally is not allocated randomly to participants. Using traditional regression models might confuse messaging and hinder policy recommendations for pollution control and disease prevention policies. METHODS We conducted a cohort study among 36,271 adults from one of the largest cities in China in 2015 and followed up through 2020. Hazard ratios of stroke admissions following long-term PM1 exposure were estimated via a causal inference approach, marginal structural time-varying Cox proportional hazard model, accounting for multiple confounders. Additionally, several sensitivity analyses and impact modification analyses were carried out. RESULTS AND DISCUSSION Associations with 1 μg/m3 increase in long-term PM1 were identified for total (HR, 1.079; 95 %CI, 1.012-1.151) and ischemic stroke admissions (HR, 1.092; 95 %CI, 1.018-1.171). The harmful associations varied with exposure duration, initially increasing and then decreasing. The 2-3 years cumulative exposure was associated with a 3.3-5.4 % raised risk for total stroke. For every 1 μg/m³ increase in long-term PM1 exposure, females exhibited a higher risk of both total and ischemic stroke (13 % and 16 %) than men (4 % and 5 %). Low-exposure individuals (whose annual PM1 concentrations were under the third quartile among the annual concentrations for all the participants) exhibited greater sensitivity to PM1 effects (total stroke: 1.079 vs. 1.107; ischemic stroke: 1.092 vs. 1.116). The results underline the importance of safeguarding low-exposed people in highly polluted areas and suggest that long-term PM1 exposure may increase stroke admission risk, warranting attention to vulnerable groups.
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Affiliation(s)
- Shirui Chen
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Yuqin Zhang
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Jing Wei
- Department of Atmospheric and Oceanic Science, Earth System Science Interdisciplinary Center, University of Maryland, College Park, MD, USA
| | - Chun Hao
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Wenjing Wu
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Zhiqiang Li
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Tong Guo
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Ziqiang Lin
- Department of Preventive Medicine, School of Basic Medicine and Public Health, Jinan University, Guangzhou, China.
| | - Wangjian Zhang
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China.
| | - Yuantao Hao
- Peking University Center for Public Health and Epidemic Preparedness & Response, Peking, China; Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, China.
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Aoyama BC, McGrath-Morrow SA, Collaco JM. Social determinants of health and somatic growth in preterm infants and children with chronic lung disease. Pediatr Pulmonol 2024. [PMID: 39212242 DOI: 10.1002/ppul.27237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 07/17/2024] [Accepted: 08/17/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE Bronchopulmonary dysplasia (BPD), a common complication of prematurity, is associated with impaired lung function and increased morbidity in childhood. These children display heterogeneous somatic growth patterns which may ultimately impact their risk for later respiratory disease. We aim to understand the relationship between socioenvironmental exposures and growth in this population. METHODS A retrospective longitudinal cohort study was conducted using participants (n = 616) enrolled in the Johns Hopkins Outpatient BPD Registry. Growth measurements between 0 and 36 months of age were obtained. Somatic growth measurements, both corrected and uncorrected for gestational age, were converted to z-scores using Center for Disease Control and Prevention normative data. Using a participant's residential zip code, we utilized the 2019 Area Deprivation Index (ADI), the Childhood Opportunity Index (COI) 2.0, and neighborhood food insecurity data from the Maryland Food Bank. Linear regression analysis was performed employing individual socioenvironmental measures as independent variables and growth z-scores as dependent variables in univariate analysis. Univariate analysis was repeated adjusting for gestational age, BPD severity, and the presence of a gastrostomy tube (GT). RESULTS Of the three measures analyzed, national COI (nCOI) showed a significant association with mean weight z-scores, mean ADI showed some association with mean weight z-scores, and the percentage of a community experiencing food insecurity showed no association with mean weight z-scores. After adjusting for gestational age, BPD severity, and presence of a GT, children living in areas of greater opportunity (higher nCOI values), had significantly lower weight z-scores at 12 months corrected and at 24 and 36 months uncorrected CONCLUSIONS: Our findings suggest that the COI 2.0, a multidimensional measure, captures more facets of an individual's social environment, as compared to the singular nature of a measure of food insecurity. There are several potential explanations for the phenomenon seen, and further understanding of this dynamic is crucial for designing effective interventions and policies to better address inequities in outcomes.
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Affiliation(s)
- Brianna C Aoyama
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sharon A McGrath-Morrow
- Division of Pediatric Pulmonology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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5
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Kim HA, Yu AG, Kim NP, Iqbal MS, Butts R. Lower opportunity ZIP code is associated with worse outcomes after listing in pediatric heart transplantation. J Heart Lung Transplant 2024; 43:1298-1307. [PMID: 38704128 DOI: 10.1016/j.healun.2024.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/14/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND The Child Opportunity Index (COI) comprehensively measures children's social determinants of health. We describe association between COI and outcomes after listing for heart transplantation. METHODS We conducted a retrospective review of the United Network for Organ Sharing (UNOS) database for U.S. children listed for heart transplant between 2012 and 2020. ZIP codes were utilized to assign COI. Primary outcome was survival from time of listing. Secondary outcomes included waitlist survival, 1-year post-transplant survival, and conditional 1-year post-transplant survival. Cox regression was performed adjusting for payor, age, race, diagnosis, and support at listing for all outcomes except waitlist survival, for which Fine-Gray competing risk analysis was performed. RESULTS Of 5,723 children listed, 109 were excluded due to missing ZIP codes. Race/ethnicity and payor were associated with COI (p < 0.001). Patients living in very low COI ZIP codes compared to all others had increased mortality from time of listing (HR 1.16, CI 1.03-1.32, p = 0.02) with 1-, 5-, and 9-year survival of 79.3% vs 82.2%, 66.5% vs 73.0%, and 53.6% vs 64.7% respectively, were more likely to be removed from the waitlist due to death or being too sick (subdistribution HR 1.26, 95% CI 1.10-1.42), and had increased mortality conditional on one-year post-transplant survival (HR 1.38, 1.09-1.74, p = 0.008) with 1-, 3-, and 5- year survival of 94.7% vs 97.3%, 87.0% vs 93.1%, and 78.6% vs 86.9%. CONCLUSIONS Children living in lower opportunity ZIP codes had poorer survival from time of listing, poorer waitlist survival, and poorer conditional one-year post-transplant survival.
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Affiliation(s)
- Heidi A Kim
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Andrew G Yu
- Division of Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Nicole P Kim
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, Texas
| | - Mehreen S Iqbal
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Ryan Butts
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas.
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Liberman DB, Tam JS, Cushing AM, Espinoza J. A novel tool using social and environmental determinants of health to assess pediatric asthma in the emergency department. J Am Coll Emerg Physicians Open 2024; 5:e13240. [PMID: 39144726 PMCID: PMC11322657 DOI: 10.1002/emp2.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 05/08/2024] [Accepted: 06/26/2024] [Indexed: 08/16/2024] Open
Abstract
Asthma, the most common chronic disease in children, affects more than 4 million children in the United States, disproportionately affecting those who are economically disadvantaged and racial and ethnic minorities. Studies have shown that the racial and ethnic disparities in asthma outcomes can be largely explained by environmental, socioeconomic and other social determinants of health (SDoH). Utilizing new approaches to stratify disease severity and risk, which focus on the underlying SDoH that lead to asthma disparity, provides an opportunity to disentangle race and ethnicity from its confounding social determinants. In particular, with the growing use of geospatial information systems, geocoded data can enable researchers and clinicians to quantify social and environmental impacts of structural racism. When these data are systematically collected and tabulated, researchers, and ultimately clinicians at the bedside, can evaluate patients' neighborhood context and create targeted interventions toward those factors most associated with asthma morbidity. To do this, we have designed a view (mPage in the Cerner electronic health record) that centralizes key clinical information and displays it alongside SDoH variables shown to be linked to asthma incidence and severity. Once refined and validated, which is the next step in our project, our goal is for emergency medicine clinicians to use these data in real time while caring for patients with asthma. Our multidisciplinary, patient-centered approach that leverages modern informatics tools will create opportunities to better triage patients with asthma exacerbations, choose the best interventions, and target underlying determinants of disease.
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Affiliation(s)
- Danica B. Liberman
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
- Department of Pediatrics, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Department of Population and Public Health Sciences, Keck School of MedicineUniversity of SouthernLos AngelesCaliforniaUSA
| | - Jonathan S. Tam
- Department of Pediatrics, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Division of Clinical Immunology and AllergyChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Anna M. Cushing
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
- Department of Pediatrics, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Juan Espinoza
- Department of Pediatrics, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Division of General PediatricsChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
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7
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Titus AR, Terlizzi K, Conderino S, Ðoàn LN, Kim B, Thorpe LE. Patterns and drivers of disparities in pediatric asthma outcomes among Medicaid-enrolled children living in subsidized housing in NYC. Prev Med 2024; 185:108023. [PMID: 38908569 DOI: 10.1016/j.ypmed.2024.108023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/13/2024] [Accepted: 05/29/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE There are persistent disparities in pediatric asthma morbidity in the U.S. We linked claims data with information on neighborhood-level risk factors to explore drivers of asthma disparities among Medicaid-enrolled children in New York City subsidized housing. METHODS We constructed a cohort of Medicaid-enrolled children living in public or other subsidized housing, based on residential address, in NYC between 2016 and 2019 (n = 108,969). We examined claims-derived asthma prevalence across age and racial and ethnic groups, integrating census tract-level information and using the Bayesian Improved Surname Geocoding (BISG) algorithm to address high rates of missing data in self-reported race and ethnicity. We used inverse probability weighting (IPW) to explore the extent to which disparities persisted when exposure to asthma risk factors - related to the built environment, neighborhood poverty, and air quality - were balanced across groups. This analysis was conducted in 2022-2023. RESULTS Claims-derived asthma prevalence was highest among children <7 years at baseline and among non-Hispanic Black and Hispanic children. For example, among children aged 3-6 years at baseline, claims-derived prevalence was 17.3% and 18.1% among non-Hispanic Black and Hispanic children, respectively, compared to 9.3% and 9.0% among non-Hispanic White and non-Hispanic Asian American/Pacific Islander children. Using IPW to balance exposure to asthma risk factors across racial and ethnic groups attenuated, but did not eliminate, disparities in asthma prevalence. CONCLUSIONS We found high asthma burden among children living in subsidized housing. Modifiable place-based characteristics may be important contributors to pediatric asthma disparities.
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Affiliation(s)
- Andrea R Titus
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America.
| | - Kelly Terlizzi
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Sarah Conderino
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Lan N Ðoàn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Byoungjun Kim
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Lorna E Thorpe
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
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Unaka N, Kahn RS, Spitznagel T, Henize AW, Carlson D, Michael J, Quinonez E, Anderson J, Beck AF. An Institutional Approach to Equity and Improvement in Child Health Outcomes. Pediatrics 2024; 154:e2023064994. [PMID: 38953125 PMCID: PMC11464011 DOI: 10.1542/peds.2023-064994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 07/03/2024] Open
Abstract
Pediatric health inequities are pervasive. Approaches by health care institutions to address inequities often, and increasingly, focus on social needs screening without linked, robust responses. Even when actions in pursuit of health equity do occur within health care institutions, efforts occur in isolation from each other, standing in the way of cross-learning and innovation. Learning network methods hold promise when institutions are confronted with complex, multidimensional challenges. Equity-oriented learning networks may therefore accelerate action to address complex factors that contribute to inequitable pediatric health outcomes, enabling rapid learning along the way. We established an institutional Health Equity Network (HEN) in pursuit of excellent and equitable health outcomes for children and adolescents in our region. The HEN supports action teams seeking to eliminate pediatric health inequities in their clinical settings. Teams deploy targeted interventions to meet patients' and families' needs, addressing both medical and social factors affecting health and wellbeing. The primary, shared HEN measure is the equity gap in hospitalization rates between Black patients and all other patients. The HEN currently has 10 action teams and promotes rapid learning and scaling of interventions via monthly "action period calls" and "solutions labs" focused on successes, challenges, and potential common solutions (eg, scaling of existing medical-legal partnership to subspecialty clinics). In this Advocacy Case Study, we detail the design, implementation, and early outcomes from the HEN, our equity-oriented learning network.
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Affiliation(s)
- Ndidi Unaka
- Division of Hospital Medicine, Cincinnati Children’s, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s, Cincinnati, Ohio
- Michael Fisher Child Health Equity Center, Cincinnati Children’s, Cincinnati, Ohio
- Office of Population Health, Cincinnati Children’s, Cincinnati, Ohio
| | - Robert S. Kahn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s, Cincinnati, Ohio
- Michael Fisher Child Health Equity Center, Cincinnati Children’s, Cincinnati, Ohio
- Division of General and Community Pediatrics, Cincinnati Children’s, Cincinnati, Ohio
| | - Tony Spitznagel
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s, Cincinnati, Ohio
| | - Adrienne W. Henize
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Michael Fisher Child Health Equity Center, Cincinnati Children’s, Cincinnati, Ohio
- Division of General and Community Pediatrics, Cincinnati Children’s, Cincinnati, Ohio
| | - David Carlson
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s, Cincinnati, Ohio
- Michael Fisher Child Health Equity Center, Cincinnati Children’s, Cincinnati, Ohio
| | - Joseph Michael
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s, Cincinnati, Ohio
- Michael Fisher Child Health Equity Center, Cincinnati Children’s, Cincinnati, Ohio
| | - Elizabeth Quinonez
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s, Cincinnati, Ohio
- Michael Fisher Child Health Equity Center, Cincinnati Children’s, Cincinnati, Ohio
| | - Jeffrey Anderson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s, Cincinnati, Ohio
- Office of Population Health, Cincinnati Children’s, Cincinnati, Ohio
- The Heart Institute, Cincinnati Children’s, Cincinnati, Ohio
| | - Andrew F. Beck
- Division of Hospital Medicine, Cincinnati Children’s, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s, Cincinnati, Ohio
- Michael Fisher Child Health Equity Center, Cincinnati Children’s, Cincinnati, Ohio
- Office of Population Health, Cincinnati Children’s, Cincinnati, Ohio
- Division of General and Community Pediatrics, Cincinnati Children’s, Cincinnati, Ohio
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9
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Khalid M, Almasri T, Goble S, Johnson D, Gilbertson D, Linzer M, Strykowski R. Seasonal variations and social disparities in asthma hospitalizations and outcomes. J Asthma 2024:1-9. [PMID: 39046135 DOI: 10.1080/02770903.2024.2383630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/09/2024] [Accepted: 07/19/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVE Exposure to asthma exacerbating triggers may be dependent on the season and an individual's social factors and subsequent means to avoid triggers. We assessed for seasonal variations and differential outcomes based on race and income in admissions for asthma in a United States nationwide assessment. METHODS This retrospective study assessed adult hospitalizations for asthma 2016-2019 using the National Inpatient Sample. Hospitalizations were categorized by season: winter (December-February), spring (March-May), summer (June-August), fall (September-November). Multivariable linear and logistic regression were used to assess associations between season, race, income quartile (determined by the median income within a patient's ZIP code), and outcomes. RESULTS The study included 423,140 admissions with a mean age of 51 years, and 73% of the cohort being female and 56% non-white. Admissions peaked during winter (124, 145) and were lowest in summer (80,525). Intubation rates were increased in summer compared to winter (2.73 vs 1.93%, aOR = 1.19, 95% CI: 1.04-1.37) as were rates of noninvasive positive pressure ventilation (NIPPV) (7.92 vs 7.06%, aOR = 1.08, 95% CI: 1.00-1.17). Compared to white patients, intubation (2.53 vs 1.87%, absolute difference 0.66%, aOR = 1.14, 95% CI: 1.02-1.29) and NIPPV (9.95 vs 5.45%, absolute difference 4.5%, aOR = 1.69, 95% CI: 1.57-1.82) were increased in Black patients. No significant associations between income and clinical outcomes were found. CONCLUSIONS Asthma admission peak during winter, while summer admissions and non-white race are associated with higher rates of NIPPV and intubation. Public health initiatives and strategically timed outpatient visits could combat seasonal variation and social disparities in asthma outcomes.
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Affiliation(s)
- Mohammed Khalid
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Talal Almasri
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Spencer Goble
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | | | - David Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Mark Linzer
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
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10
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Kranjac AW, Kain ZN, Ehwerhemuepha L, Weiss M, Jenkins BN. Neighborhood Socioeconomic Context Predicts Pediatric Asthma Exacerbation. Clin Pediatr (Phila) 2024:99228241262997. [PMID: 39044420 DOI: 10.1177/00099228241262997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
Causes of asthma exacerbation in children have been studied extensively at the individual level, but contributions of neighborhood-level factors are less explored. We test which distinctive residential characteristics produce variation in uncontrolled asthma among pediatric patients. We extracted electronic medical record data from pediatric patients living in Southern California and used multilevel modeling techniques to isolate which neighborhood characteristics drive inequitable asthma control. Above and beyond the individual-level factors known to predict inadequate disease control, neighborhoods with greater concentration of non-Hispanic black residents (odds ratios [OR] = 1.02; 95% confidence interval [CI]: 0.99-1.03; P < .05), higher proportions of female-headed households (OR = 1.01; 95% CI: 0.99-1.01; P < .05), and higher levels of ambient air pollution (OR = 1.05; 95% CI: 1.01-1.10; P < .001) associate with greater odds of asthma exacerbation. The interplay between community characteristics and asthma management during childhood is complex, and place-based initiatives are needed to narrow the gap in asthma exacerbation.
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Affiliation(s)
- Ashley W Kranjac
- Department of Sociology, Chapman University, Orange, CA, USA
- Center on Stress & Health, School of Medicine, University of California, Irvine, Irvine, CA, USA
- The Earl Babbie Research Center, Chapman University, Orange, CA, USA
| | - Zeev N Kain
- Center on Stress & Health, School of Medicine, University of California, Irvine, Irvine, CA, USA
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, CA, USA
- Yale Child Study Center, Yale University, New Haven, CT, USA
| | - Louis Ehwerhemuepha
- Computational Research, Research Institute, Children's Health of Orange County, Orange, CA, USA
| | - Michael Weiss
- Pediatrics, Children's Health of Orange County, Orange, CA, USA
| | - Brooke N Jenkins
- Center on Stress & Health, School of Medicine, University of California, Irvine, Irvine, CA, USA
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, CA, USA
- Department of Psychology, Chapman University, Orange, CA, USA
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11
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Fitzpatrick AM, Grunwell JR, Gaur H, Kobara S, Kamaleswaran R. Plasma metabolomics identifies differing endotypes of recurrent wheezing in preschool children differentiated by symptoms and social disadvantage. Sci Rep 2024; 14:15813. [PMID: 38982241 PMCID: PMC11233605 DOI: 10.1038/s41598-024-66878-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/04/2024] [Indexed: 07/11/2024] Open
Abstract
Preschool children with recurrent wheezing are a heterogeneous population with many underlying biological pathways that contribute to clinical presentations. Although the morbidity of recurrent wheezing in preschool children is significant, biological studies in this population remain quite limited. To address this gap, this study performed untargeted plasma metabolomic analyses in 68 preschool children with recurrent wheezing to identify metabolomic endotypes of wheezing. K-means cluster analysis was performed on metabolomic dataset including a total of 1382 named and unnamed metabolites. We identified three metabolomic clusters which differed in symptom severity, exacerbation occurrence, and variables associated with social disadvantage. Metabolites that distinguished the clusters included those involved in fatty acid metabolism, fatty acids (long chain monounsaturated fatty acids, long chain polyunsaturated fatty acids, and long chain saturated fatty acids), lysophospholipids, phosphatidylcholines, and phosphatidylethanolamines. Pathway analyses identified pathways of interest in each cluster, including steroid metabolism, histidine metabolism, sphingomyelins, and sphingosines, among others. This study highlights the biologic complexity of recurrent wheezing in preschool children and offers novel metabolites and pathways that may be amenable to future study and intervention.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive Office #340, 30322, Atlanta, Georgia.
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive Office #340, 30322, Atlanta, Georgia
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hina Gaur
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, Georgia
| | - Seibi Kobara
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, Georgia
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12
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Skeen EH, Moore CM, Federico MJ, Seibold MA, Liu AH, Hamlington KL. The Child Opportunity Index 2.0 and exacerbation-prone asthma in a cohort of urban children. Pediatr Pulmonol 2024; 59:1894-1904. [PMID: 38558492 DOI: 10.1002/ppul.26998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Abstract
RATIONALE Social determinants of health underlie disparities in asthma. However, the effects of individual determinants likely interact, so a summary metric may better capture their impact. The Child Opportunity Index 2.0 (COI) is one such tool, yet its association with exacerbation-prone (EP) asthma is unknown. OBJECTIVE To investigate the association between the COI and EP asthma and clinical measures of asthma severity in children. METHODS We analyzed data from two prospective observational pediatric asthma cohorts (n = 193). Children were classified as EP (≥1 exacerbation in the past 12 months) or exacerbation-null (no exacerbations in the past 5 years). Spirometry, exhaled nitric oxide, IgE, and Composite Asthma Severity Index (CASI) were obtained. The association between COI and EP status was assessed with logistic regression. We fit linear and logistic regression models to test the association between COI and each clinical measure. RESULTS A 20-point COI decrease conferred 40% higher odds of EP asthma (OR 1.4; 95%CI 1.1-1.76). The effect was similar when adjusted for age and sex (OR 1.38, 95%CI 1.1-1.75) but was attenuated with additional adjustment for race and ethnicity (OR 1.19, 95%CI 0.92-1.54). A similar effect was seen for the Social/Economic and Education COI domains but not the Health/Environment Domain. A 20-point COI decrease was associated with an increase in CASI of 0.34. COI was not associated with other clinical measures. CONCLUSIONS Lower COI was associated with greater odds of EP asthma. This highlights the potential use of the COI to understand neighborhood-level risk and identify community targets to reduce asthma disparities.
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Affiliation(s)
- Emily H Skeen
- Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Camille M Moore
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado, USA
| | - Monica J Federico
- Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Max A Seibold
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado, USA
| | - Andrew H Liu
- Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Katharine L Hamlington
- Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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13
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Wadhwani SI, Alvarado A, Shifman HP, Bautista B, Yalung J, Squires JE, Campbell K, Ebel NH, Hsu E, Vittorio J, Zielsdorf S, Desai DM, Bucuvalas JC, Gottlieb L, Kotagal U, Lyles CR, Ackerman SL, Lai JC. Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study. Liver Transpl 2024; 30:717-727. [PMID: 38166123 PMCID: PMC11176037 DOI: 10.1097/lvt.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/12/2023] [Indexed: 01/04/2024]
Abstract
Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.
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Affiliation(s)
| | | | | | | | - Jared Yalung
- University of California, San Francisco, San Francisco, CA
| | | | | | | | - Evelyn Hsu
- Seattle Children’s Hospital, Seattle, WA
| | - Jennifer Vittorio
- Columbia University Medical Center, New York, NY
- New York University Langone Health, New York, NY
| | | | | | | | - Laura Gottlieb
- University of California, San Francisco, San Francisco, CA
| | - Uma Kotagal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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14
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Payne AS, Moore K, Casazza A, Parikh K, Cora-Bramble D. Initiative to Increase Equity in Clinical Care: Experience at 1 Children's Hospital. Pediatrics 2024; 153:e2023063096. [PMID: 38747040 DOI: 10.1542/peds.2023-063096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 06/02/2024] Open
Affiliation(s)
- Asha S Payne
- Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine, Washington, District of Columbia; and
| | - Katharine Moore
- Children's National Hospital, Washington, District of Columbia
| | - Angelina Casazza
- Children's National Hospital, Washington, District of Columbia
- Angelina Casazza Consulting, Kensington, Maryland
| | - Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine, Washington, District of Columbia; and
| | - Denice Cora-Bramble
- Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine, Washington, District of Columbia; and
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15
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Gaietto K, Han YY, Rosser FJ, Acosta-Pérez E, Forno E, Canino G, Celedón JC. Socioeconomic status, diet, and recurrent severe asthma exacerbations in Puerto Rican youth. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100220. [PMID: 38375461 PMCID: PMC10875262 DOI: 10.1016/j.jacig.2024.100220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 02/21/2024]
Abstract
Background Why Puerto Rican youths have higher rates of severe asthma exacerbations (SAEs) than their non-Hispanic White peers is unclear. Objective We aimed to identify risk factors associated with recurrent SAEs in Puerto Rican youths with asthma. Methods We performed cross-sectional and longitudinal analyses of recurrent SAEs in 209 Puerto Rican youths with asthma who participated in 2 cross-sectional studies approximately 5.2 years apart: the Puerto Rico Genetics of Asthma and Lifestyle study (visit 1, participants aged 6-14 years) and the Epigenetic Variation and Childhood Asthma in Puerto Ricans study (visit 2, participants aged 9-20 years). Recurrent SAEs were defined as at least 2 SAEs in the previous year. Results Of the youths in our study, there were 80 (38.3%) and 47 (22.4%) with recurrent SAEs at visit 1 and visit 2, respectively, and 31 participants (14.8%) had persistent recurrent SAEs (ie, recurrent SAEs at both visits). In multivariable analyses, low household income was significantly associated with 2.4 to 12.3 times increased odds of recurrent SAEs in all analyses, with stronger longitudinal associations. Low parental education level, nonprivate or employer-based health insurance, overweight or obesity, residential proximity to a major road, and low or moderate level of outdoor activity were each significantly associated with recurrent SAEs in at least 1 analysis. Further, persistence of low parental numeracy level, low household income, and an unhealthy diet were each associated with persistent recurrent SAEs. Conclusion In this study of Puerto Rican youths with asthma, persistence of low parental numeracy level, a low household income, and an unhealthy diet were associated with persistent recurrent SAEs. Our findings support policies promoting equity and healthy lifestyles for Puerto Rican children and their families.
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Affiliation(s)
- Kristina Gaietto
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pa
| | - Yueh-Ying Han
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pa
| | - Franziska J. Rosser
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pa
| | - Edna Acosta-Pérez
- Behavioral Sciences Research Institute, University of Puerto Rico, San Juan, Puerto Rico
| | - Erick Forno
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pa
| | - Glorisa Canino
- Behavioral Sciences Research Institute, University of Puerto Rico, San Juan, Puerto Rico
| | - Juan C. Celedón
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pa
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16
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Brokamp C, Jones MN, Duan Q, Rasnick Manning E, Ray S, Corley AMS, Michael J, Taylor S, Unaka N, Beck AF. Causal Mediation of Neighborhood-Level Pediatric Hospitalization Inequities. Pediatrics 2024; 153:e2023064432. [PMID: 38426267 DOI: 10.1542/peds.2023-064432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Population-wide racial inequities in child health outcomes are well documented. Less is known about causal pathways linking inequities and social, economic, and environmental exposures. Here, we sought to estimate the total inequities in population-level hospitalization rates and determine how much is mediated by place-based exposures and community characteristics. METHODS We employed a population-wide, neighborhood-level study that included youth <18 years hospitalized between July 1, 2016 and June 30, 2022. We defined a causal directed acyclic graph a priori to estimate the mediating pathways by which marginalized population composition causes census tract-level hospitalization rates. We used negative binomial regression models to estimate hospitalization rate inequities and how much of these inequities were mediated indirectly through place-based social, economic, and environmental exposures. RESULTS We analyzed 50 719 hospitalizations experienced by 28 390 patients. We calculated census tract-level hospitalization rates per 1000 children, which ranged from 10.9 to 143.0 (median 45.1; interquartile range 34.5 to 60.1) across included tracts. For every 10% increase in the marginalized population, the tract-level hospitalization rate increased by 6.2% (95% confidence interval: 4.5 to 8.0). After adjustment for tract-level community material deprivation, crime risk, English usage, housing tenure, family composition, hospital access, greenspace, traffic-related air pollution, and housing conditions, no inequity remained (0.2%, 95% confidence interval: -2.2 to 2.7). Results differed when considering subsets of asthma, type 1 diabetes, sickle cell anemia, and psychiatric disorders. CONCLUSIONS Our findings provide additional evidence supporting structural racism as a significant root cause of inequities in child health outcomes, including outcomes at the population level.
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Affiliation(s)
- Cole Brokamp
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Margaret N Jones
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Qing Duan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Sarah Ray
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexandra M S Corley
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joseph Michael
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stuart Taylor
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ndidi Unaka
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew F Beck
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
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17
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Beck AF, Seid M, McDowell KM, Udoko M, Cronin SC, Makrozahopoulos D, Powers T, Fairbanks S, Prideaux J, Vaughn LM, Hente E, Thurmond S, Unaka NI. Building a regional pediatric asthma learning health system in support of optimal, equitable outcomes. Learn Health Syst 2024; 8:e10403. [PMID: 38633017 PMCID: PMC11019385 DOI: 10.1002/lrh2.10403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/18/2023] [Accepted: 11/27/2023] [Indexed: 04/19/2024] Open
Abstract
Introduction Asthma is characterized by preventable morbidity, cost, and inequity. We sought to build an Asthma Learning Health System (ALHS) to coordinate regional pediatric asthma improvement activities. Methods We generated quantitative and qualitative insights pertinent to a better, more equitable care delivery system. We used electronic health record data to calculate asthma hospitalization rates for youth in our region. We completed an "environmental scan" to catalog the breadth of asthma-related efforts occurring in our children's hospital and across the region. We supplemented the scan with group-level assessments and focus groups with parents, clinicians, and community partners. We used insights from this descriptive epidemiology to inform the definition of shared aims, drivers, measures, and prototype interventions. Results Greater Cincinnati's youth are hospitalized for asthma at a rate three times greater than the U.S. average. Black youth are hospitalized at a rate five times greater than non-Black youth. Certain neighborhoods bear the disproportionate burden of asthma morbidity. Across Cincinnati, there are many asthma-relevant activities that seek to confront this morbidity; however, efforts are largely disconnected. Qualitative insights highlighted the importance of cross-sector coordination, evidence-based acute and preventive care, healthy homes and neighborhoods, and accountability. These insights also led to a shared, regional aim: to equitably reduce asthma-related hospitalizations. Early interventions have included population-level pattern recognition, multidisciplinary asthma action huddles, and enhanced social needs screening and response. Conclusion Learning health system methods are uniquely suited to asthma's complexity. Our nascent ALHS provides a scaffold atop which we can pursue better, more equitable regional asthma outcomes.
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Affiliation(s)
- Andrew F. Beck
- Division of General & Community PediatricsCincinnati Children'sCincinnatiOhioUSA
- Division of Hospital MedicineCincinnati Children'sCincinnatiOhioUSA
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
- Michael Fisher Child Health Equity CenterCincinnati Children'sCincinnatiOhioUSA
- Office of Population HealthCincinnati Children'sCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Michael Seid
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children'sCincinnatiOhioUSA
| | - Karen M. McDowell
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children'sCincinnatiOhioUSA
| | - Mfonobong Udoko
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children'sCincinnatiOhioUSA
| | - Susan C. Cronin
- Division of Pulmonary MedicineCincinnati Children'sCincinnatiOhioUSA
| | | | - Tricia Powers
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
| | - Sonja Fairbanks
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
| | - Jonelle Prideaux
- Division of Emergency MedicineCincinnati Children'sCincinnatiOhioUSA
- Qualitative Methods & Analysis CollaborativeCincinnati Children'sCincinnatiOhioUSA
| | - Lisa M. Vaughn
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Emergency MedicineCincinnati Children'sCincinnatiOhioUSA
- Qualitative Methods & Analysis CollaborativeCincinnati Children'sCincinnatiOhioUSA
- Criminal Justice, & Human ServicesUniversity of Cincinnati College of EducationCincinnatiOhioUSA
| | | | - Sophia Thurmond
- Department of Information ServicesCincinnati Children'sCincinnatiOhioUSA
| | - Ndidi I. Unaka
- Division of Hospital MedicineCincinnati Children'sCincinnatiOhioUSA
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children'sCincinnatiOhioUSA
- Michael Fisher Child Health Equity CenterCincinnati Children'sCincinnatiOhioUSA
- Office of Population HealthCincinnati Children'sCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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18
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Perry TT, Marko A, Russell AF, Cooke AT, Bingemann TA, Ross KR, Young MC. How Schools Can Help Address Social Determinants of Health in Asthma Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:316-326. [PMID: 37839577 DOI: 10.1016/j.jaip.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
Schools are in a unique position to address social determinants of health (SDOHs) in pediatric asthma management because of their potential to provide resources and facilitate collaboration with health care providers and services for children at risk within their community. SDOHs include economic factors, educational attainment and health literacy, neighborhood factors and the built environment, social and community aspects including discrimination and racism, and health care access and quality. These factors have a significant impact on asthma health in children, and certain populations such as minoritzed populations and those living in high-poverty environments have been shown to be at greater risk for adverse effects of SDOHs on asthma outcomes. School-based asthma programs address several SDOHs including health literacy, the built environment, and health care quality and access and have been shown to improve asthma outcomes. Key components include connection between the school and the health care team, self-management education, and directly observed therapy. School nurses play a key role in directing and managing effective programs because they can evaluate and support a student's health while considering the effect of SDOHs at interpersonal, institutional, community, and policy levels.
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Affiliation(s)
- Tamara T Perry
- Division of Allergy and Immunology, College of Medicine, Arkansas Children's Research Institute, University of Arkansas for Medical Sciences, Little Rock, Ark
| | - Angela Marko
- Division of Pediatric Pulmonology and Sleep Medicine, UH Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio.
| | - Anne F Russell
- School of Nursing and Health Sciences, Spring Arbor University, Spring Arbor, Mich; Food Allergy and Anaphylaxis Michigan Association, Ann Arbor, Mich
| | - Abigail T Cooke
- Allergy and Asthma Specialists, Durango, Colo; Colorado State University-Pueblo: Graduate School of Nursing, Pueblo, Colo
| | - Theresa A Bingemann
- Departments of Allergy, Immunology and Rheumatology and Pediatric Allergy and Immunology, University of Rochester School of Medicine, Rochester, NY
| | - Kristie R Ross
- Division of Pediatric Pulmonology and Sleep Medicine, UH Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Michael C Young
- Division of Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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19
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Correa-Agudelo E, Gautam Y, Mendy A, Mersha TB. Racial differences in length of stay and readmission for asthma in the all of us research program. J Transl Med 2024; 22:22. [PMID: 38178151 PMCID: PMC10768130 DOI: 10.1186/s12967-023-04826-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND This study addresses the limited research on racial disparities in asthma hospitalization outcomes, specifically length of stay (LOS) and readmission, across the U.S. METHODS We analyzed in-patient and emergency department visits from the All of Us Research Program, identifying various risk factors (demographic, comorbid, temporal, and place-based) associated with asthma LOS and 30-day readmission using Bayesian mixed-effects models. RESULTS Of 17,233 patients (48.0% White, 30.7% Black, 19.7% Hispanic/Latino, 1.3% Asian, and 0.3% Middle Eastern and North African) with 82,188 asthma visits, Black participants had 20% shorter LOS and 12% higher odds of readmission, compared to White participants in multivariate analyses. Public-insured patients had 14% longer LOS and 39% higher readmission odds than commercially insured patients. Weekend admissions resulted in a 12% shorter LOS but 10% higher readmission odds. Asthmatics with chronic diseases had a longer LOS (range: 6-39%) and higher readmission odds (range: 9-32%) except for those with allergic rhinitis, who had a 23% shorter LOS. CONCLUSIONS A comprehensive understanding of the factors influencing asthma hospitalization, in conjunction with diverse datasets and clinical-community partnerships, can help physicians and policymakers to systematically address racial disparities, healthcare utilization and equitable outcomes in asthma care.
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Affiliation(s)
- Esteban Correa-Agudelo
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Yadu Gautam
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Angelico Mendy
- Division of Epidemiology, Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tesfaye B Mersha
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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20
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Tyris J, Gourishankar A, Kachroo N, Teach SJ, Parikh K. The Child Opportunity Index and asthma morbidity among children younger than 5 years old in Washington, DC. J Allergy Clin Immunol 2024; 153:103-110.e5. [PMID: 37877904 DOI: 10.1016/j.jaci.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Place-based social determinants of health are associated with pediatric asthma morbidity. However, there is little evidence on how social determinants of health correlate to the disproportionately high rates of asthma morbidity experienced by children <5 years old. OBJECTIVES This study sought to evaluate census tract associations between the Child Opportunity Index ±COI) and at-risk rates (ARRs) for pediatric asthma-related emergency department (ED) encounters and hospitalizations in Washington, DC. METHODS This was a cross-sectional study of children <5 years old with physician-diagnosed asthma included in the DC Asthma Registry between January 2018 and December 2019. Census tract COI score (1-100) and its 3 domains (social/economic, health/environmental, and educational) were the exposures (source: www.diversitydatakids.org). ED and hospitalization ARRs (outcomes) were created by dividing counts of ED encounters and hospitalizations by populations with asthma for each census tract and adjusted for population-level demographic (age, sex, insurance), clinical (asthma severity), and community (violent crime and limited English proficiency) covariates. RESULTS Within a study population of 3806 children with a mean age of 2.4 ± 1.4 years, 2132 (56%) had 5852 ED encounters, and 821 (22%) had 1418 hospitalizations. Greater census tract overall COI, social/economic COI, and educational COI were associated with fewer ED ARRs. There were no associations between the health/environmental COI and ED ARRs or between the COI and hospitalization ARRs. CONCLUSION Improving community-level social, economic, and educational opportunity within specific census tracts may reduce ED ARRs in this population.
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Affiliation(s)
- Jordan Tyris
- Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington.
| | - Anand Gourishankar
- Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington
| | - Nikita Kachroo
- Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington
| | - Stephen J Teach
- Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington
| | - Kavita Parikh
- Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington
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21
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Emmanuel M, Margolis R, Badh R, Kachroo N, Teach SJ, Parikh K. Caregiver Language Preference and Health Care Utilization Among Children With Asthma. Pediatrics 2023; 152:e2023061869. [PMID: 37964708 DOI: 10.1542/peds.2023-061869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Asthma is a leading cause of health care utilization in children and disproportionately affects historically marginalized populations. Yet, limited data exist on the role of caregiver language preference on asthma morbidity. The study aim was to determine whether caregiver non-English language preference (NELP) is associated with unscheduled asthma-related health care utilization in pediatric patients. METHODS This was a retrospective cohort study using data from a population-level, disease-specific registry of pediatric patients with asthma living in the District of Columbia (DC). Patients aged 2 to 17 years were included and the study period was 2019. The primary exposure variable was language preference: English preferred (EP) or NELP by self-identified language preference. The primary outcome was unscheduled asthma-related health care utilization including emergency department visits, hospitalizations (ICU and non-ICU), and ICU visits alone. Logistic regression was used to calculate adjusted odds ratios (aORs). RESULTS Of the 14 431 patients included, 8.1% had NELP (1172 patients). In analyses adjusted for age, sex, ethnicity, insurance status, diagnosis of persistent asthma, controller prescription, and encounter with a primary care provider, caregiver NELP was associated with an increased odds of having an asthma-related emergency department visit (aOR, 1.37; 95% CI, 1.08-1.74), hospitalization (aOR, 1.79; 95% CI, 1.18-2.72), and ICU visit (aOR, 4.37; 95% CI, 1.93-9.92). In the Hispanic subgroup (n = 1555), caregiver NELP was associated with an increased odds of having an asthma-related hospitalization (aOR, 1.73; 95% CI, 1.02-2.93). CONCLUSIONS In the population of children in the District of Columbia with asthma, caregiver NELP was associated with increased odds of asthma-related health care utilization, suggesting that caregiver language preference is a significant determinant of asthma outcomes.
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Affiliation(s)
| | | | | | | | - Stephen J Teach
- Division of Emergency Medicine
- Center for Translational Research
| | - Kavita Parikh
- Center for Translational Research
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
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22
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Freyleue SD, Arakelyan M, Leyenaar JK. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States: 2019 update. J Hosp Med 2023; 18:908-917. [PMID: 37661338 DOI: 10.1002/jhm.13194] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/01/2023] [Accepted: 08/11/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND General hospitals (GH) provide inpatient care for the majority of hospitalized children in the United States, yet the majority of hospital pediatrics research is conducted at freestanding children's hospitals. OBJECTIVE Updating a prior 2012 analysis, this study used 2019 data to describe characteristics of pediatric hospitalizations at general and freestanding hospitals in the United States and identify the most common and costly reasons for hospitalization in these settings. DESIGNS, SETTING, AND PARTICIPANTS This study examined hospitalizations in children <18 years using the Healthcare Cost and Utilization Project's 2019 Kids' Inpatient Database, stratifying neonatal and nonneonatal hospital stays. INTERVENTION Not applicable. MAIN OUTCOME AND MEASURES Sociodemographic and clinical differences between hospitalizations at general and freestanding children's hospitals were examined, applying survey weights to generate national estimates. RESULTS There were an estimated 5,263,218 pediatric hospitalizations in 2019, including 3,757,601 neonatal and 1,505,617 nonneonatal hospital stays. Overall, 88.6% (n = 4,661,288) of hospitalizations occurred at GH, including 97.6% of neonatal hospitalizations and 65.9% of nonneonatal hospitalizations. 11.4% (n = 601,930) of hospitalizations occurred at freestanding children's hospitals, including 2.4% (n = 88,313) of neonatal hospitalizations and 34.1% (n = 513,616) of nonneonatal hospitalizations. In total, 98.9% of complicated birth hospitalizations and 66.0% of neonatal nonbirth hospitalizations occurred at GH. Among nonneonatal stays, 85.2% of mental health hospitalizations, 63.5% of medical hospitalizations, and 61.3% of surgical hospitalizations occurred at GH.
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Affiliation(s)
- Seneca D Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire, USA
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire, USA
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23
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Warniment A, Sauers-Ford H, Brady PW, Beck AF, Callahan SR, Giambra BK, Herzog D, Huang B, Loechtenfeldt A, Loechtenfeldt L, Miller CL, Perez E, Riddle SW, Shah SS, Shepard M, Sucharew HJ, Tegtmeyer K, Thomson JE, Auger KA. Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial. J Hosp Med 2023; 18:877-887. [PMID: 37602537 DOI: 10.1002/jhm.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Children and young adults with medical complexity (CMC) experience high rates of healthcare reutilization following hospital discharge. Prior studies have identified common hospital-to-home transition failures that may increase the risk for reutilization, including medication, technology and equipment issues, financial concerns, and confusion about which providers can help with posthospitalization needs. Few interventions have been developed and evaluated for CMC during this transition period. OBJECTIVE We will compare the effectiveness of the garnering effective telehealth 2 help optimize multidisciplinary team engagement (GET2HOME) transition bundle intervention to the standard hospital-based care coordination discharge process by assessing healthcare reutilization and patient- and family-centered outcomes. DESIGNS, SETTINGS, AND PARTICIPANTS We will conduct a pragmatic 2-arm randomized controlled trial (RCT) comparing the GET2HOME bundle intervention to the standard hospital-based care discharge process on CMC hospitalized and discharged from hospital medicine at two sites of our pediatric medical center between November 2022 and February 2025. CMC of any age will be identified as having complex chronic disease using the Pediatric Medical Complexity Algorithm tool. We will exclude CMC who live independently, live in skilled nursing facilities, are in custody of the county, or are hospitalized for suicidal ideation or end-of-life care. INTERVENTION We will randomize participants to the bundle intervention or standard hospital-based care coordination discharge process. The bundle intervention includes (1) predischarge telehealth huddle with inpatient providers, outpatient providers, patients, and their families; (2) care management discharge task tracker; and (3) postdischarge telehealth huddle with similar participants within 7 days of discharge. As part of the pragmatic design, families will choose if they want to complete the postdischarge huddle. The standard hospital-based discharge process includes a pharmacist, social worker, and care management support when consulted by the inpatient team but does not include huddles between providers and families. MAIN OUTCOME AND MEASURES Primary outcome will be 30-day urgent healthcare reutilization (unplanned readmission, emergency department, and urgent care visits). Secondary outcomes include 7-day urgent healthcare reutilization, patient- and family-reported transition quality, quality of life, and time to return to baseline using electronic health record and surveys at 7, 30, 60, and 90 days following discharge. We will also evaluate heterogeneity of treatment effect for the intervention across levels of financial strain and for CMC with high-intensity neurologic impairment. The primary analysis will follow the intention-to-treat principle with logistic regression used to study reutilization outcomes and generalized linear mixed modeling to study repeated measures of patient- and family-reported outcomes over time. RESULTS This pragmatic RCT is designed to evaluate the effectiveness of enhanced discharge transition support, including telehealth huddles and a care management discharge tool, for CMC and their families. Enrollment began in November 2022 and is projected to complete in February 2025. Primary analysis completion is anticipated in July 2025 with reporting of results following.
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Affiliation(s)
- Amanda Warniment
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hadley Sauers-Ford
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew F Beck
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Cincinnati Children's HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Michael Fisher Child Health Equity Center Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Scott R Callahan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Barbara K Giambra
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, USA
| | - Diane Herzog
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bin Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Allison Loechtenfeldt
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Chelsey L Miller
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Combined Pediatrics/Medicine House Staff, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital, Cincinnati, Ohio, USA
| | | | - Sarah W Riddle
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Heidi J Sucharew
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Telehealth, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joanna E Thomson
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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24
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Stern KE, Hicks S, Gavin AR, Littman AJ, Wander PL. Cross-sectional Associations of Multiracial Identity with Self-Reported Asthma and Poor Health Among American Indian and Alaska Native Adults. J Racial Ethn Health Disparities 2023; 10:2444-2452. [PMID: 36205849 DOI: 10.1007/s40615-022-01423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/05/2022] [Accepted: 09/27/2022] [Indexed: 10/10/2022]
Abstract
INTRODUCTION American Indian and Alaska Native (AI/AN) multiracial subgroups are underrecognized in health outcomes research. METHODS We performed a cross-sectional analysis of Behavioral Risk Factor Surveillance System surveys (2013-2019), including adults who self-identified as AI/AN only (single race AI/AN, n = 60,413) or as AI/AN and at least one other race (multiracial AI/AN, (n = 6056)). We used log binomial regression to estimate the survey-weighted prevalence ratios (PR) and 95% confidence intervals (CI) of lifetime asthma, current asthma, and poor self-reported health among multiracial AI/AN adults compared to single race AI/AN adults, adjusting for age, obesity, and smoking status. We then examined whether associations differed by sex and by Latinx identity. RESULTS Lifetime asthma, current asthma, and poor health were reported by 25%, 18%, and 30% of multiracial AI/AN adults and 18%, 12%, and 28% single race AI/AN adults. Multiracial AI/AN was associated with a higher prevalence of lifetime (PR 1.30, 95% CI 1.18-1.43) and current asthma (PR 1.36, 95% CI 1.21-1.54), but not poor health. Associations did not differ by sex. The association of multiracial identity with current asthma was stronger among AI/AN adults who identified as Latinx (PR 1.77, 95% CI 1.08-2.94) than non-Latinx AI/AN (PR 1.18, 95% CI 1.04-1.33), p-value for interaction 0.03. CONCLUSIONS Multiracial AI/AN adults experience a higher prevalence of lifetime and current asthma compared to single race AI/AN adults. The association between multiracial identity and current asthma is stronger among AI/AN Latinx individuals. The mechanisms for these findings remain under-explored and merit further study.
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Affiliation(s)
- Katherine E Stern
- University of Washington School of Public Health, Seattle, WA, USA.
- University of California San Francisco East Bay Surgery Program, Oakland, CA, USA.
| | - Sarah Hicks
- University of Washington School of Public Health, Seattle, WA, USA
| | - Amelia R Gavin
- University of Washington School of Social Work, Seattle, WA, USA
| | - Alyson J Littman
- University of Washington School of Public Health, Seattle, WA, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
| | - Pandora L Wander
- University of Washington Department of Medicine, Seattle, WA, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
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25
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Leyenaar JK, Freyleue SD, Arakelyan M, Goodman DC, O’Malley AJ. Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019. JAMA Netw Open 2023; 6:e2331807. [PMID: 37656457 PMCID: PMC10474556 DOI: 10.1001/jamanetworkopen.2023.31807] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/07/2023] [Indexed: 09/02/2023] Open
Abstract
Importance National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. Objective To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. Design, Setting, and Participants This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Exposures Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. Main Outcomes and Measures The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. Results The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Conclusions and Relevance Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - Seneca D. Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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26
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Keim G, Hsu JY, Pinto NP, McSherry ML, Gula AL, Christie JD, Yehya N. Readmission Rates After Acute Respiratory Distress Syndrome in Children. JAMA Netw Open 2023; 6:e2330774. [PMID: 37682574 PMCID: PMC10492185 DOI: 10.1001/jamanetworkopen.2023.30774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 09/09/2023] Open
Abstract
Importance An increasing number of children survive after acute respiratory distress syndrome (ARDS). The long-term morbidity affecting these survivors, including the burden of hospital readmission and key factors associated with readmission, is unknown. Objective To determine 1-year readmission rates among survivors of pediatric ARDS and to investigate the associations of 3 key index hospitalization factors (presence or development of a complex chronic condition, receipt of a tracheostomy, and hospital length of stay [LOS]) with readmission. Design, Setting, and Participants This retrospective cohort study used data from the commercial or Medicaid IBM MarketScan databases between 2013 and 2017, with follow-up data through 2018. Participants included hospitalized children (aged ≥28 days to <18 years) who received mechanical ventilation and had algorithm-identified ARDS. Data analysis was completed from March 2022 to March 2023. Exposures Complex chronic conditions (none, nonrespiratory, and respiratory), receipt of tracheostomy, and index hospital LOS. Main Outcomes and Measures The primary outcome was 1-year, all-cause hospital readmission. Univariable and multivariable Cox proportional hazard models were created to test the association of key hospitalization factors with readmission. Results One-year readmission occurred in 3748 of 13 505 children (median [IQR] age, 4 [0-14] years; 7869 boys [58.3%]) with mechanically ventilated ARDS who survived to hospital discharge. In survival analysis, the probability of 1-year readmission was 30.0% (95% CI, 29.0%-30.8%). One-half of readmissions occurred within 61 days of discharge (95% CI, 56-67 days). Both respiratory (adjusted hazard ratio [aHR], 2.69; 95% CI, 2.42-2.98) and nonrespiratory (aHR, 1.86; 95% CI, 1.71-2.03) complex chronic conditions were associated with 1-year readmission. Placement of a new tracheostomy (aHR, 1.98; 95% CI, 1.69-2.33) and LOS 14 days or longer (aHR, 1.87; 95% CI, 1.62-2.16) were associated with readmission. After exclusion of children with chronic conditions, LOS 14 days or longer continued to be associated with readmission (aHR, 1.92; 95% CI, 1.49-2.47). Conclusions and Relevance In this retrospective cohort study of children with ARDS who survived to discharge, important factors associated with readmission included the presence or development of chronic medical conditions during the index admission, tracheostomy placement during index admission, and index hospitalization of 14 days or longer. Future studies should evaluate whether postdischarge interventions (eg, telephonic contact, follow-up clinics, and home health care) may help reduce the readmission burden.
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Affiliation(s)
- Garrett Keim
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Neethi P. Pinto
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Megan L. McSherry
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Annie Laurie Gula
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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27
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Jefferson AA, Brown CC, Eyimina A, Goudie A, Rezaeiahari M, Perry TT, Tilford JM. Asthma Quality Measurement and Adverse Outcomes in Medicaid-Enrolled Children. Pediatrics 2023; 152:e2022059812. [PMID: 37497577 PMCID: PMC10389769 DOI: 10.1542/peds.2022-059812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVES To determine the association between the asthma medication ratio (AMR) quality measure and adverse outcomes among Medicaid-enrolled children with asthma in Arkansas, given concerns regarding the utility of the AMR in evaluating pediatric risk of asthma-related adverse events (AAEs). METHODS We used the Arkansas All-Payer Claims Database to identify Medicaid-enrolled children with asthma using a nonrestrictive case definition and additionally using the standard Healthcare Effectiveness Data and Information Set (HEDIS) persistent asthma definition. We assessed the AMR using the traditional dichotomous HEDIS AMR categorization and across 4 expanded AMR categories. Regression models assessed associations between AMR and AAE including hospitalization and emergency department utilization, with models conducted overall and by race and ethnicity. RESULTS Of the 22 788 children in the analysis, 9.0% had an AAE (6.7% asthma-related emergency department visits; 3.0% asthma-related hospitalizations). We found poor correlation between AMR and AAE, with higher rates of AAE (10.5%) among children with AMR ≥0.5 compared with AMR <0.5 (8.5%; P < .001), and similar patterns stratified by racial and ethnic subgroups. Expanded AMR categorization revealed notable differences in associations between AMR and AAEs, compared with traditional dichotomous categorization, with worse performance in Black children. CONCLUSIONS The AMR performed poorly in identifying risk of adverse outcomes among Medicaid-enrolled children with asthma. These findings underscore concerns of the utility of the AMR in population health management and reliance on restrictive HEDIS definitions. New population health frameworks incorporating broader considerations that accurately identify at-risk children are needed to improve equity in asthma management and outcomes.
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Affiliation(s)
- Akilah A. Jefferson
- Department of Pediatrics, Allergy & Immunology Division
- Arkansas Children’s Research Institute, Little Rock, Arkansas
| | - Clare C. Brown
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Arina Eyimina
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Anthony Goudie
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mandana Rezaeiahari
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Tamara T. Perry
- Department of Pediatrics, Allergy & Immunology Division
- Arkansas Children’s Research Institute, Little Rock, Arkansas
| | - J. Mick Tilford
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Chen S, Lin X, Du Z, Zhang Y, Zheng L, Ju X, Guo T, Wang X, Chen L, Jiang J, Hu W, Zhang W, Hao Y. Potential causal links between long-term ambient particulate matter exposure and cerebrovascular mortality: Insights from a large cohort in southern China. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2023; 328:121336. [PMID: 36822305 DOI: 10.1016/j.envpol.2023.121336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 05/09/2023]
Abstract
Cohort studies conducted in North America and Europe have linked cerebrovascular mortality to long-term exposure to particulate matter (PM). However, limited evidence from large cohorts in high-exposure areas and the traditional approach of association assessment may cause residual confounding issues. In this study, we aimed to investigate the causal links between cerebrovascular mortality and long-term exposure to PM2.5, PM10, and PM2.5-10 in an ongoing cohort study with 580,757 participants in southern China. Using satellite-based estimates of PM concentration at a 1-km2 spatial resolution, we assigned exposure levels to each participant and used the marginal structural Cox model to assess the association between PM exposure and cerebrovascular mortality while accounting for time-varying covariates. We also explored the potential modification effects of sociodemographic and behavioral factors on the PM-health associations. Adjusted hazard ratios (HR) for overall cerebrovascular mortality were 1.041 (95% confidence interval (CI): 1.034-1.049) and 1.032 (95% CI: 1.026-1.038) for each 1 μg/m3 increase in PM2.5, and PM10, respectively. Similar trends were observed in the mortality risk from stroke and ischemic stroke, with HRs ranging from 1.040 to 1.069 and 1.025 to 1.052, respectively, across 2 p.m. exposures. The impact of PM exposure was generally more apparent among women, participants with primary school diplomas and below, and the subgroup under low-exposure. Multiple sensitivity analyses confirmed the robustness of the results. In conclusion, this sizable prospective cohort study hypothesizes causal links between long-term PM exposure and cerebrovascular mortality, particularly among vulnerable participants, supporting the rationale for reducing PM concentration in China to reduce cerebrovascular mortality.
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Affiliation(s)
- Shirui Chen
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Xiao Lin
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Zhicheng Du
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Yuqin Zhang
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Lingling Zheng
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Xu Ju
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Tong Guo
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Xinran Wang
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Lichang Chen
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Jie Jiang
- Peking University Center for Public Health and Epidemic Preparedness & Response, Peking, China
| | - Weihua Hu
- Peking University Center for Public Health and Epidemic Preparedness & Response, Peking, China
| | - Wangjian Zhang
- Department of Medical Statistics, School of Public Health & Center for Health Information Research & Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Yuantao Hao
- Peking University Center for Public Health and Epidemic Preparedness & Response, Peking, China.
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Fitzpatrick AM, Diani B, Kavalieratos D, Corace EA, Mason C, Van Dresser M, Grunwell JR. Poorer Caregiver Mental and Social Health Is Associated With Worse Respiratory Outcomes in Preschool Children With Recurrent Wheezing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1814-1822. [PMID: 36868472 PMCID: PMC10258161 DOI: 10.1016/j.jaip.2023.02.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Mental and social health in caregivers of preschool children has been inadequately studied, but it may influence respiratory symptom recognition and management. OBJECTIVE To identify preschool caregivers at highest risk for poor mental and social health outcomes on the basis of patient-reported outcome measures. METHODS Female caregivers 18 to 50 years old (N = 129) with a preschool child aged 12 to 59 months with recurrent wheezing and at least 1 exacerbation in the previous year completed 8 validated patient-reported outcome measures of mental and social health. k-means cluster analysis was performed using the T score for each instrument. Caregiver/child dyads were followed for 6 months. Primary outcomes included caregiver quality of life and wheezing episodes in their preschool children. RESULTS Three clusters of caregivers were identified: low risk (n = 38), moderate risk (n = 56), and high risk (n = 35). The high-risk cluster had the lowest life satisfaction, meaning and purpose, and emotional support and the highest social isolation, depression, anger, perceived stress, and anxiety that persisted for more than 6 months. This cluster had the poorest quality of life and marked disparities in social determinants of health. Preschool children from caregivers in the high-risk cluster had more frequent respiratory symptoms and a higher occurrence of any wheezing episode, but a lower outpatient physician utilization for wheezing management. CONCLUSIONS Caregiver mental and social health is associated with respiratory outcomes in preschool children. Routine assessment of mental and social health in caregivers is warranted to promote health equity and improve wheezing outcomes in preschool children.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Badiallo Diani
- Department of Biomedical Engineering, Emory University, Atlanta, Ga; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Ga
| | - Dio Kavalieratos
- Department of Family and Preventative Medicine, Emory University, Atlanta, Ga
| | | | | | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
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Correa-Agudelo E, Ding L, Beck AF, Mendy A, Mersha TB. Multilevel Analysis of Racial and Ethnic Disparities in COVID-19 Hospitalization among Children with Allergies. Ann Am Thorac Soc 2023; 20:843-853. [PMID: 36622831 PMCID: PMC10257024 DOI: 10.1513/annalsats.202207-580oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/09/2023] [Indexed: 01/10/2023] Open
Abstract
Rationale: Previous studies have identified risk factors for coronavirus disease (COVID-19) hospitalization in children. However, these studies have been limited in their ability to disentangle the contribution of racial disparities, allergic comorbidities, and environmental exposures to the development of severe COVID-19 in at-risk children with allergies. Objectives: To examine racial and ethnic disparities in COVID-19 hospitalization and their links to potentially underlying allergic comorbidities and individual and place-based factors in children with allergies. Methods: This is an electronic health record-based retrospective study of children in 2020. The outcome was COVID-19 hospitalization categorized as no hospital care for patients with asymptomatic/mild illness, short stay for patients admitted and discharged within 24 hours, and prolonged stay for patients requiring additional time to discharge (more than 24 h). Mixed-effects and mediation models were used to determine relationships among independent variables, mediators, and COVID-19 hospitalization. Results: Among the 5,258 children with COVID-19 positive test or diagnosis, 10% required a short stay, and 3.7% required a prolonged stay. Black and Hispanic children had higher odds of longer stays than non-Hispanic White children (both P < 0.001). Children with obesity and eosinophilic esophagitis diagnoses had higher odds of short and prolonged stay (all P < 0.05). Area-level deprivation was associated with short stay (adjusted odds ratio [AOR], 15.49; 95% confidence interval [CI], 5.16-45.47 for every 0.1-unit increase) and prolonged stay (AOR, 11.82; 95% CI, 2.25-62.01 for every 0.1-unit increase). Associations between race/ethnicity and COVID-19 hospitalization were primarily mediated by insurance and area-level deprivation, altogether accounting for 99% of the variation in COVID-19 hospitalization. Conclusions: There were racial and ethnic differences in children with allergies and individual and place-based factors related to COVID-19 hospitalization. Differences were primarily mediated by insurance and area-level deprivation, altogether accounting for 99% of the variation in COVID-19 hospitalization. A better understanding of COVID-related morbidity in children and the link to place-based factors is key to developing prevention strategies capable of equitably improving outcomes.
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Affiliation(s)
| | - Lili Ding
- Division of Biostatistics and Epidemiology
| | - Andrew F. Beck
- Division of General & Community Pediatrics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, and
| | - Angelico Mendy
- Division of Epidemiology, Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio
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31
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Gautam Y, Mersha TB. Leveraging genetic ancestry to study severe asthma exacerbations in an admixed population. Thorax 2023; 78:220-221. [PMID: 36400457 PMCID: PMC9957837 DOI: 10.1136/thorax-2022-219459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Yadu Gautam
- Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tesfaye B Mersha
- Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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32
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Aggarwal S, Cepalo T, Gill S, Thipse M, Clifton KL, Higginson A, Vu J, Bijelić V, Barrowman N, Giangioppo S, Radhakrishnan D. Factors associated with future hospitalization among children with asthma: a systematic review. J Asthma 2023; 60:425-445. [PMID: 35522051 DOI: 10.1080/02770903.2022.2070762] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Asthma is a leading cause of emergency department (ED) visits and hospitalizations in children, though many could be prevented. Our study objective was to identify factors from the published literature that are associated with future hospitalization for asthma beyond 30 days following an initial asthma ED visit. DATA SOURCES We searched CINAHL, CENTRAL, MEDLINE, and Embase for all studies examining factors associated with asthma-related hospitalization in children from January 1, 1992 to February 7, 2022.Selecting Studies: All citations were reviewed independently by two reviewers and studies meeting inclusion criteria were assessed for risk of bias. Data on all reported variables were extracted from full text and categorized according to identified themes. Where possible, data were pooled for meta-analysis using random effects models. RESULTS Of 2262 studies, 68 met inclusion criteria. We identified 28 risk factors and categorized these into six themes. Factors independently associated with future hospitalization in meta-analysis include: exposure to environmental tobacco smoke (OR = 1.94 95%CI 0.67-5.61), pets exposure (OR = 1.67 95%CI 1.17-2.37), and previous asthma hospitalizations (OR = 3.47 95% CI 2.95-4.07). Additional related factors included previous acute care visits, comorbid health conditions (including atopy), allergen exposure, severe-persistent asthma phenotype, inhaled steroid use prior to ED visit, poor asthma control, higher severity symptoms at ED presentation, warmer season at admission, longer length of stay or ICU admission, and African-American race/ethnicity. CONCLUSIONS We identified multiple factors that are consistently associated with future asthma hospitalization in children and could be used to identify those who would benefit from targeted preventative interventions.
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Affiliation(s)
| | - Tanita Cepalo
- Faculty of Science, Carleton University, Ottawa, Canada
| | - Sana Gill
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Madhura Thipse
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Kerry-Lee Clifton
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | | | - James Vu
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Vid Bijelić
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Sandra Giangioppo
- University of Toronto, Toronto, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Dhenuka Radhakrishnan
- Children's Hospital of Eastern Ontario, Ottawa, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Canada.,ICES, Ottawa, ON, Canada
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Association of County-degree Social Vulnerability with Chronic Respiratory Disease Mortality in the United States. Ann Am Thorac Soc 2023; 20:47-57. [PMID: 36044720 DOI: 10.1513/annalsats.202202-136oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: Chronic respiratory diseases, the third leading cause of death worldwide, have been associated with significant morbidity, mortality, and increased economic burden that make a profound impact on individuals and communities. However, limited research has delineated complex relationships between specific sociodemographic disparities and chronic respiratory disease outcomes among U.S. counties. Objectives: To assess the association of county-level sociodemographic vulnerabilities with chronic respiratory disease mortality in the United States. Methods: Chronic respiratory disease mortality data among U.S. counties for 2014-2018 was obtained from the CDC WONDER (Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research) database. The social vulnerability index (SVI), including subindices of socioeconomic status, household composition and disability, minority status and language, and housing type and transportation, is a composite, percentile-based measure developed by the CDC to evaluate county-level sociodemographic vulnerabilities to disasters. We examined county-level sociodemographic characteristics from the SVI and classified the percentile rank into quartiles, with a higher quartile indicating greater vulnerability. The associations between chronic respiratory disease mortality and overall SVI, its four subindices, and each county characteristic were analyzed by negative binomial regression. Results: From 2014 to 2018, the age-adjusted mortality per 1,000,000 population attributed to chronic lower respiratory disease was 406.4 (95% confidence interval [CI], 405.5-407.3); chronic obstructive pulmonary disease (COPD), 393.7 (392.8-394.6); asthma, 10.0 (9.9-10.2); interstitial lung disease (ILD), 50.5 (50.1-50.8); idiopathic pulmonary fibrosis (IPF), 37.0 (36.7-37.3); and sarcoidosis, 5.3 (5.2-5.4). Counties in the higher quartile of overall SVI were significantly associated with greater disease mortality (chronic lower respiratory disease, incidence rate ratios: fourth vs. first quartile, 1.43 [95% CI, 1.39-1.48]; COPD, 1.44 [1.39-1.49]; asthma, 2.06 [1.71-2.48]; ILD, 1.07 [1.02-1.13]; IPF, 1.14 [1.06-1.22]; sarcoidosis, 2.01 [1.44-2.81]). In addition, higher mortality was also found in counties in the higher quartile of each subindex and most sociodemographic characteristics. Conclusions: Chronic respiratory disease mortalities were significantly associated with county-level sociodemographic determinants as measured by the SVI in the United States. These findings suggested sociodemographic determinants may add a considerable barrier to establishing health equity. Multidegree public health strategies and clinical interventions addressing inequitable outcomes of chronic respiratory disease should be developed and targeted in areas with greater social vulnerability and disadvantage.
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Correa-Agudelo E, Ding L, Beck AF, Brokamp C, Altaye M, Kahn RS, Mersha TB. Understanding racial disparities in childhood asthma using individual- and neighborhood-level risk factors. J Allergy Clin Immunol 2022; 150:1427-1436.e5. [PMID: 35970309 PMCID: PMC9887733 DOI: 10.1016/j.jaci.2022.07.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/16/2022] [Accepted: 07/11/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Racial disparities in childhood asthma outcomes result from a complex interplay of individual- and neighborhood-level factors. OBJECTIVES We sought to examine racial disparities in asthma-related emergency department (ED) visits between African American (AA) and European American (EA) children. METHODS This is a retrospective study of patients younger than 18 years who visited the ED at Cincinnati Children's for asthma from 2009 to 2018. The outcome was number of ED visits during a year. We assessed 11 social, economic, and environmental variables. Mediation and mixed-effects analyses were used to assess relationships between race, mediators, and number of ED visits. RESULTS A total of 31,114 children (46.1% AA, 53.9% EA) had 186,779 asthma-related ED visits. AA children had more visits per year than EA children (2.23 vs 2.15; P < .001). Medicaid insurance was associated with a 7% increase in rate of ED visits compared with commercial insurance (1.07; 95% CI, 1.03-1.1). Neighborhood socioeconomic deprivation was associated with an increased rate of ED visits in AA but not in EA children. Area-level particulate matter with diameter less than 2.5 μm, pollen, and outdoor mold were associated with an increased rate of ED visits for both AA and EA children (all P < .001). Associations between race and number of ED visits were mediated by insurance, area-level deprivation, particulate matter with diameter less than 2.5 μm, and outdoor mold (all P < .001), altogether accounting for 55% of the effect of race on ED visits. Race was not associated with number of ED visits (P = .796) after accounting for mediators. CONCLUSIONS Racial disparities in asthma-related ED visits are mediated by social, economic, and environmental factors, which may be amenable to interventions aimed at improving outcomes and eliminating inequities.
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Affiliation(s)
- Esteban Correa-Agudelo
- Divisions of Asthma Research, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Lili Ding
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Andrew F Beck
- Divisions of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio; Divisions of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Cole Brokamp
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Mekibib Altaye
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Robert S Kahn
- Divisions of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Tesfaye B Mersha
- Divisions of Asthma Research, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio.
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35
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Wadhwani SI, Barrera AG, Shifman HP, Baker E, Bucuvalas J, Gottlieb LM, Kotagal U, Rhee SJ, Lai JC, Lyles CR. Caregiver perspectives on the everyday medical and social needs of long-term pediatric liver transplant patients. Liver Transpl 2022; 28:1735-1746. [PMID: 35524767 PMCID: PMC9949888 DOI: 10.1002/lt.26498] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 02/05/2023]
Abstract
Using in-depth interviews, we sought to characterize the everyday medical and social needs of pediatric liver transplant caregivers to inform the future design of solutions to improve care processes. Participants (parents/caregivers of pediatric liver transplant recipients) completed a survey (assessing socioeconomic status, economic hardship, health literacy, and social isolation). We then asked participants to undergo a 60-min virtual, semistructured qualitative interview to understand the everyday medical and social needs of the caregiver and their household. We intentionally oversampled caregivers who reported a social or economic hardship on the survey. Transcripts were analyzed using thematic analysis and organized around the Capability, Opportunity, Motivation-Behavior model. A total of 18 caregivers participated. Of the participants, 50% reported some form of financial strain, and about half had less than 4 years of college education. Caregivers had high motivation and capability in executing transplant-related tasks but identified several opportunities for improving care. Caregivers perceived the health system to lack capability in identifying and intervening on specific family social needs. Caregiver interviews revealed multiple areas in which family supports could be strengthened, including (1) managing indirect costs of prolonged hospitalizations (e.g., food, parking), (2) communicating with employers to support families' needs, (3) coordinating care across hospital departments, and (4) clarifying care team roles in helping families reduce both medical and social barriers. This study highlights the caregiver perspective on barriers and facilitators to posttransplant care. Future work should identify whether these themes are present across transplant centers. Caregiver perspectives should help inform future interventions aimed at improving long-term outcomes for children after liver transplantation.
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Affiliation(s)
| | | | - Holly P. Shifman
- Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Ethel Baker
- University of California, San Francisco, San Francisco, CA
| | - John Bucuvalas
- Icahn School of Medicine at Mount Sinai, New York, NY
- Kravis Children’s Hospital, New York, NY
| | | | - Uma Kotagal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sue J. Rhee
- University of California, San Francisco, San Francisco, CA
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Yu AG, Hall M, Agharokh L, Lee BC, Zaniletti I, Wilson KM, Williams DJ. Hospital-Level Neighborhood Opportunity and Rehospitalization for Common Diagnoses at US Children's Hospitals. Acad Pediatr 2022; 22:1459-1467. [PMID: 35728729 DOI: 10.1016/j.acap.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Neighborhood conditions influence child health outcomes, but data examining association between local factors and hospital utilization are lacking. We determined if hospitals' mix of patients by neighborhood opportunity correlates with rehospitalization for common diagnoses at US children's hospitals. METHODS We analyzed all discharges in 2018 for children ≤18 years at 47 children's hospitals for 14 common diagnoses. The exposure was hospital-level mean neighborhood opportunity - measured by Child Opportunity Index (COI) - for each diagnosis. The outcome was same-cause rehospitalization within 365 days. We measured association via Pearson correlation coefficient. For diagnoses with significant associations, we also examined shorter rehospitalization time windows and compared unadjusted and COI-adjusted rehospitalization rates. RESULTS There were 256,871 discharges included. Hospital-level COI ranged from 17th to 70th percentile nationally. Hospitals serving lower COI neighborhoods had more frequent rehospitalization for asthma (ρ -0.34 [95% confidence interval -0.57, -0.06]) and diabetes (ρ -0.33 [-0.56, -0.04]), but fewer primary mental health rehospitalizations (ρ 0.47 [0.21, 0.67]). There was no association for 11 other diagnoses. Secondary timepoint analysis revealed increasing correlation over time, with differences by diagnosis. Adjustment for hospital-level COI resulted in 26%, 32%, and 45% of hospitals changing >1 decile in rehospitalization rank order for diabetes, asthma, and mental health diagnoses, respectively. CONCLUSIONS Children's hospitals vary widely in their mix of neighborhoods served. Asthma, diabetes, and mental health rehospitalization rates correlate with COI, suggesting that neighborhood factors may influence outcome disparities for these conditions. Hospital outcomes may be affected by neighborhood opportunity, which has implications for benchmarking.
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Affiliation(s)
- Andrew G Yu
- Division of Hospital Medicine, Department of Pediatrics (AG Yu, L Agharokh and BC Lee), University of Texas Southwestern Medical Center and Children's Health, Dallas, Tex.
| | - Matt Hall
- Children's Hospital Association (M Hall and I Zaniletti), Lenexa, Kans
| | - Ladan Agharokh
- Division of Hospital Medicine, Department of Pediatrics (AG Yu, L Agharokh and BC Lee), University of Texas Southwestern Medical Center and Children's Health, Dallas, Tex
| | - Benjamin C Lee
- Division of Hospital Medicine, Department of Pediatrics (AG Yu, L Agharokh and BC Lee), University of Texas Southwestern Medical Center and Children's Health, Dallas, Tex
| | | | - Karen M Wilson
- Department of Pediatrics (KM Wilson), University of Rochester Medical Center, Rochester, NY
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics (DJ Williams), Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
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Sengupta A, Gauvreau K, Bucholz EM, Newburger JW, Del Nido PJ, Nathan M. Contemporary Socioeconomic and Childhood Opportunity Disparities in Congenital Heart Surgery. Circulation 2022; 146:1284-1296. [PMID: 36164982 DOI: 10.1161/circulationaha.122.060030] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND While singular measures of socioeconomic status have been associated with outcomes after surgery for congenital heart disease, the multifaceted pathways through which a child's environment impacts similar outcomes remain incompletely characterized. We sought to evaluate the association between childhood opportunity level and adverse outcomes after congenital heart surgery. METHODS Data from patients undergoing congenital cardiac surgery from January 2011 to January 2020 at a quaternary referral center were retrospectively reviewed. Outcomes of interest included predischarge (early) mortality or transplant, postoperative hospital length-of-stay, inpatient cost of hospitalization, postdischarge (late) mortality or transplant, and late unplanned reintervention. The primary predictor was a US census tract-based, nationally-normed composite metric of contemporary child neighborhood opportunity comprising 29 indicators across 3 domains (education, health and environment, and socioeconomic), categorized as very low, low, moderate, high, and very high. Associations between childhood opportunity level and outcomes were evaluated using logistic regression (early mortality), generalized linear (length-of-stay and cost), Cox proportional hazards (late mortality), or competing risk (late reintervention) models, adjusting for baseline patient-related factors, case complexity, and residual lesion severity. RESULTS Of 6133 patients meeting entry criteria, the median age was 2.0 years (interquartile range, 3.6 months-8.3 years). There were 124 (2.0%) early deaths or transplants, the median postoperative length-of-stay was 7 days (interquartile range, 5-13 days), and the median inpatient cost was $76 000 (interquartile range, $50 000-130 000). No significant association between childhood opportunity level and early mortality or transplant was observed (P=0.21). On multivariable analysis, children with very low and low opportunity had significantly longer length-of-stay and incurred higher costs compared with those with very high opportunity (all P<0.05). Of 6009 transplant-free survivors of hospital discharge, there were 175 (2.9%) late deaths or transplants, and 1008 (16.8%) reinterventions at up to 10.5 years of follow-up. Patients with very low opportunity had a significantly greater adjusted risk of late death or transplant (hazard ratio, 1.7 [95% CI, 1.1-2.6]; P=0.030) and reintervention (subdistribution hazard ratio, 1.9 [95% CI, 1.5-2.3]; P<0.001), versus those with very high opportunity. CONCLUSIONS Childhood opportunity level is independently associated with adverse outcomes after congenital heart surgery. Children from resource-limited settings thus constitute an especially high-risk cohort that warrants closer surveillance and tailored interventions.
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Affiliation(s)
- Aditya Sengupta
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA
| | - Kimberlee Gauvreau
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Emily M Bucholz
- Cardiology (K.G., E.M.B., J.W.N.), Boston Children's Hospital, MA
| | - Jane W Newburger
- Cardiology (K.G., E.M.B., J.W.N.), Boston Children's Hospital, MA.,Departments of Pediatrics (J.W.N.), Harvard Medical School, Boston, MA
| | - Pedro J Del Nido
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Surgery (P.J.dN., M.N.), Harvard Medical School, Boston, MA
| | - Meena Nathan
- Departments of Cardiac Surgery (A.S., P.J.dN., M.N.), Boston Children's Hospital, MA.,Surgery (P.J.dN., M.N.), Harvard Medical School, Boston, MA
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Tyris J, Gourishankar A, Ward MC, Kachroo N, Teach SJ, Parikh K. Social Determinants of Health and At-Risk Rates for Pediatric Asthma Morbidity. Pediatrics 2022; 150:188586. [PMID: 35871710 DOI: 10.1542/peds.2021-055570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Compared with population-based rates, at-risk rates (ARRs) account for underlying variations of asthma prevalence. When applied with geospatial analysis, ARRs may facilitate more accurate evaluations of the contribution of place-based social determinants of health (SDOH) to pediatric asthma morbidity. Our objectives were to calculate ARRs for pediatric asthma-related emergency department (ED) encounters and hospitalizations by census-tract in Washington, the District of Columbia (DC) and evaluate their associations with SDOH. METHODS This population-based, cross-sectional study identified children with asthma, 2 to 17 years old, living in DC, and included in the DC Pediatric Asthma Registry from January 2018 to December 2019. ED encounter and hospitalization ARRs (outcomes) were calculated for each DC census-tract. Five census-tract variables (exposures) were selected by using the Healthy People 2030 SDOH framework: educational attainment, vacant housing, violent crime, limited English proficiency, and families living in poverty. RESULTS During the study period, 4321 children had 7515 ED encounters; 1182 children had 1588 hospitalizations. ARRs varied 10-fold across census-tracts for both ED encounters (64-728 per 1000 children with asthma) and hospitalizations (20-240 per 1000 children with asthma). In adjusted analyses, decreased educational attainment was significantly associated with ARRs for ED encounters (estimate 12.1, 95% confidence interval [CI] 8.4 to 15.8, P <.001) and hospitalizations (estimate 1.2, 95% CI 0.2 to 2.2, P = .016). Violent crime was significantly associated with ARRs for ED encounters (estimate 35.3, 95% CI 10.2 to 60.4, P = .006). CONCLUSION Place-based interventions addressing SDOH may be an opportunity to reduce asthma morbidity among children with asthma.
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Affiliation(s)
- Jordan Tyris
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia.,George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Anand Gourishankar
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia.,George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Maranda C Ward
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Nikita Kachroo
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia
| | - Stephen J Teach
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia.,George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Kavita Parikh
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia.,George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Sindher SB, Fast K, Nadeau KC, Chinthrajah RS. Providing a Safe Nest for Improved Health Care Outcomes in Pregnant Women With Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1784-1787. [PMID: 35306179 DOI: 10.1016/j.jaip.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 06/14/2023]
Abstract
There is a large unmet disease burden arising from asthma in pregnancy. Pregnant women affected by moderate to severe asthma have an increased risk for adverse perinatal outcomes. This can be worsened by social determinants of health, which are social and environmental conditions that affect health and the quality of life. Here we present the case of a medically complex pregnant woman with worsening asthma and challenges in optimizing positive outcomes for both the mother and baby during the perinatal period. This case captures several elements of social determinants of health that affect health outcomes most notably in non-White patients, including chronic exposure to air pollution contributing to asthma severity and reduced access to health care specialists.
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Affiliation(s)
- Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Katharine Fast
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif.
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The Effect of Outdoor Environmental Exposure on Readmission Rates for Children and Adolescents with Asthma-A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127457. [PMID: 35742711 PMCID: PMC9223649 DOI: 10.3390/ijerph19127457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/14/2022] [Accepted: 06/14/2022] [Indexed: 12/10/2022]
Abstract
The burden of asthma readmission for children and adolescents is approximately 10% worldwide. Research has been synthesised for behavioural and indoor impacts; however, no such synthesis has been conducted for outdoor environmental exposures. This systematic review aims to evaluate and synthesise the impact the outdoor environment has on readmission rates for children or adolescents with asthma. We conducted a systematic search of seven databases and hand searched reference lists of articles published up until 18 January 2021. There were 12 out of 392 studies eligible for inclusion. Overall, most studies showed that outdoor environments impact on readmission; however, the strength of association is seen to be stronger in a particular subpopulation of each study depending on the exposure investigated. The evidence for the association between outdoor environmental exposure and readmission rates for children or adolescents with asthma is increasing; however, it is complicated by potential confounders such as socioeconomic factors, ethnicity, indoor air pollutants, and other behavioural factors. Further research is required to differentiate between them. Additionally, further studies need to be undertaken in further countries other than the United States of America to understand the full relationship.
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Baker JA, Moore HM, Brinton JT, Federico MJ. Comprehensive In-Patient Education Consult for Asthma Exacerbations. Respir Care 2022; 67:682-687. [PMID: 35228306 PMCID: PMC9994195 DOI: 10.4187/respcare.08778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Asthma is the most common chronic disease leading to hospital admissions and readmissions in childhood. Bedside nurses and respiratory therapists are the primary asthma educators, but they may lack time or knowledge to provide comprehensive asthma education and identify barriers to care. Patients and their parent(s) may benefit from comprehensive education and assessment of barriers from a certified asthma educator. METHODS A team of certified asthma educators used a quality improvement method to create an in-patient asthma education consulting service. The in-patient pulmonary consult and medical teams referred subjects ≥ 1 y in age with a new or existing diagnosis of asthma who had been admitted to the ICU or identified as having concerns for poor medication adherence to the asthma consult. The asthma consult provided face-to-face education with the subject and parent(s), addressed barriers to the plan of care, and helped facilitate appointments to an asthma specialist after discharge. RESULTS There were 126 subjects eligible for the asthma consult pilot implemented October 1, 2018-April 30, 2020. The asthma consult saw 52 subjects. Subjects who received consults had a higher rate of previous health care utilization and existing specialist for asthma. After the in-patient stay, the odds of returning to the emergency department/urgent care (UC) or hospital within the following 12 months did not differ between asthma consult and control group. However, after adjusting for covariates of age, race, ethnicity, previous health care utilization, and existing specialist, there was a significant difference in the odds of readmission and revisits (adjusted odds ratio 0.39 [95% CI 0.16-0.98], P = .04) for the asthma consult group compared to the control group. CONCLUSIONS Providing comprehensive, face-to-face asthma education and working with subjects and their parent(s) to address barriers to medication adherence and facilitate specialty follow-up post discharge decreased health care utilization.
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Affiliation(s)
- Joyce A Baker
- The Breathing Institute at Children's Hospital Colorado, Aurora, Colorado.
| | - Heather M Moore
- The Breathing Institute at Children's Hospital Colorado, Aurora, Colorado
| | - John T Brinton
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Monica J Federico
- The Breathing Institute at Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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MacDonald M, Chang WC, Martin LJ, Khurana Hershey GK, Biagini JM. The Pediatric Asthma Risk Score: More does not mean better. Ann Allergy Asthma Immunol 2022; 128:729-730. [PMID: 35364242 DOI: 10.1016/j.anai.2022.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/23/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Missy MacDonald
- Division of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Wan-Chi Chang
- Division of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lisa J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Gurjit K Khurana Hershey
- Division of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jocelyn M Biagini
- Division of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
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43
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Mutic AD, Mauger DT, Grunwell JR, Opolka C, Fitzpatrick AM. Social Vulnerability Is Associated with Poorer Outcomes in Preschool Children With Recurrent Wheezing Despite Standardized and Supervised Medical Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:994-1002. [PMID: 35123099 PMCID: PMC9007879 DOI: 10.1016/j.jaip.2021.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/13/2021] [Accepted: 12/31/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Social determinants of health are associated with disparate asthma outcomes in school-age children. Social determinants have not been studied in preschool children with recurrent wheezing. OBJECTIVE We hypothesized that preschool children with recurrent wheezing at highest risk of social vulnerability would have more frequent symptoms and exacerbations when followed over 1 year, despite receiving standardized and supervised asthma care. METHODS A multicenter population of adherent preschool children receiving standardized and supervised care for wheezing was stratified by a composite measure of social vulnerability based on individual-level variables. Primary outcomes included days with upper respiratory infections and days with asthma symptom flares. Other outcomes included symptom scores during upper respiratory infections and respiratory symptom flare days, exacerbation occurrence, quality of life during the exacerbation, and hospitalization. RESULTS Preschool children at highest risk of social vulnerability did not have more frequent upper respiratory infections, respiratory symptoms, or exacerbations, but instead had more severe symptoms during upper respiratory infections and respiratory flare days, as well as more severe exacerbations with significantly poorer caregiver quality of life. Children at highest risk of social vulnerability also lived in poorer housing conditions with differing exposures and self-reported triggers. CONCLUSIONS Individual-level social determinants of health reflecting social vulnerability are associated with poorer outcomes in preschool children with recurrent wheezing despite access to supervised and standardized care. Comprehensive assessment of social determinants of health is warranted in even the youngest children with wheezing, because mitigation of these social inequities is an essential first step toward improving outcomes in pediatric patients.
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Affiliation(s)
- Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Division of Biostatistics and Bioinformatics, Pennsylvania State University, Hershey, Pa
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Cydney Opolka
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Atlanta, Ga.
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Beck AF, Henize AW, Qiu T, Huang B, Zhang Y, Klein MD, Parrish D, Fink EE, Kahn RS. Reductions In Hospitalizations Among Children Referred To A Primary Care-Based Medical-Legal Partnership. Health Aff (Millwood) 2022; 41:341-349. [PMID: 35254924 DOI: 10.1377/hlthaff.2021.00905] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Medical-legal partnerships integrate legal advocates into health care settings to address health-related social needs. However, their effect on health outcomes is unclear. This retrospective cohort study examined the effect of referral to a medical-legal partnership on hospitalization rates among urban, low-income children in Greater Cincinnati, Ohio, between 2012 and 2017. We compared 2,203 children referred to a pediatric primary care-based medical-legal partnership with 100 randomly selected control cohorts drawn from 34,235 children seen concurrently but not referred. We found that the median predicted hospitalization rate for children in the year after referral was 37.9 percent lower if children received the legal intervention than if they did not. We suspect that this decrease in hospitalizations was driven by the ability of legal advocates to address acute legal needs (for example, threat of eviction and public benefit denial) and, when possible, to confront root causes of ill health (for example, unhealthy housing conditions). Interventions such as those provided through a medical-legal partnership may be important components of integrated, value-based service delivery models.
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Affiliation(s)
- Andrew F Beck
- Andrew F. Beck , University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - TingTing Qiu
- TingTing Qiu, Cincinnati Children's Hospital Medical Center
| | - Bin Huang
- Bin Huang, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center
| | - Yin Zhang
- Yin Zhang, Cincinnati Children's Hospital Medical Center
| | - Melissa D Klein
- Melissa D. Klein, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center
| | - Donita Parrish
- Donita Parrish, Legal Aid Society of Greater Cincinnati, Cincinnati, Ohio
| | - Elaine E Fink
- Elaine E. Fink, Legal Aid Society of Greater Cincinnati
| | - Robert S Kahn
- Robert S. Kahn, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center
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Kaufmann J, Marino M, Lucas J, Bailey SR, Giebultowicz S, Puro J, Ezekiel-Herrera D, Suglia SF, Heintzman J. Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma. Ann Fam Med 2022; 20:116-122. [PMID: 35346926 PMCID: PMC8959738 DOI: 10.1370/afm.2771] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/30/2021] [Accepted: 08/16/2021] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Previous work has shown that asthma-related emergency department (ED) use is greatest among Black and Latine populations, but it is unknown whether health care use for exacerbations differs across settings (outpatient, ED, inpatient) and correlates with use of routine outpatient services. We aimed to measure disparities by race, ethnicity, and language in pediatric acute asthma care using data from US primary care community health centers. METHODS In an observational study using electronic health records from community health centers in 18 states, we compared non-Hispanic Black, English-preferring Latine, Spanish-preferring Latine, and non-Hispanic White children aged 3 to 17 years on visits for clinic-coded asthma exacerbations (2012-2018). We further evaluated asthma-related ED use and inpatient admissions in a subsample of Oregon-Medicaid recipients. Covariate-adjusted odds ratios (ORs) and rate ratios (RRs) were derived using logistic or negative binomial regression analysis with generalized estimating equations. RESULTS Among 41,276 children with asthma, Spanish-preferring Latine children had higher odds of clinic visits for asthma exacerbation than non-Hispanic White peers (OR = 1.10; 95% CI, 1.02-1.18). Among the subsample of 6,555 children insured under Oregon-Medicaid, non-Hispanic Black children had higher odds and rates of asthma-related ED use than non-Hispanic White peers (OR = 1.40; 95% CI, 1.04-1.89 and RR = 1.49; 95% CI, 1.09-2.04, respectively). We observed no differences between groups in asthma-related inpatient admissions. CONCLUSIONS This study is the first to show that patterns of clinic and ED acute-care use differ for non-Hispanic Black and Spanish-preferring Latine children when compared with non-Hispanic White peers. Non-Hispanic Black children had lower use of clinics, whereas Spanish-preferring Latine children had higher use, including for acute exacerbations. These patterns of clinic use were accompanied by higher ED use among Black children. Ensuring adequate care in clinics may be important in mitigating disparities in asthma outcomes.VISUAL ABSTRACT.
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Affiliation(s)
- Jorge Kaufmann
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,Biostatistics Group, School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon
| | - Jennifer Lucas
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | | | | | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,OCHIN, Portland, Oregon
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The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits. Acad Pediatr 2022; 22:614-621. [PMID: 34929386 PMCID: PMC9169565 DOI: 10.1016/j.acap.2021.12.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.
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Comparing Artificial Intelligence and Traditional Methods to Identify Factors Associated With Pediatric Asthma Readmission. Acad Pediatr 2022; 22:55-61. [PMID: 34329757 DOI: 10.1016/j.acap.2021.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/20/2021] [Accepted: 07/20/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To identify and contrast risk factors for six-month pediatric asthma readmissions using traditional models (Cox proportional-hazards and logistic regression) and artificial neural-network modeling. METHODS This retrospective cohort study of the 2013 Nationwide Readmissions Database included children 5 to 18 years old with a primary diagnosis of asthma. The primary outcome was time to asthma readmission in the Cox model, and readmission within 180 days in logistic regression. A basic neural network construction with 2 hidden layers and multiple replications considered all dataset variables and potential variable interactions to predict 180-day readmissions. Logistic regression and neural-network models were compared on area-under-the receiver-operating curve. RESULTS Of 18,489 pediatric asthma hospitalizations, 1858 were readmitted within 180 days. In Cox and logistic models, longer index length of stay, public insurance, and nonwinter index admission seasons were associated with readmission risk, whereas micropolitan county was protective. In neural-network modeling, 9 factors were significantly associated with readmissions. Four overlapped with the Cox model (nonwinter-month admission, long length of stay, public insurance, and micropolitan hospitals), whereas 5 were unique (age, hospital bed number, teaching-hospital status, weekend index admission, and complex chronic conditions). The area under the curve was 0.592 for logistic regression and 0.637 for the neural network. CONCLUSIONS Different methods can produce different readmission models. Relying on traditional modeling alone overlooks key readmission risk factors and complex factor interactions identified by neural networks.
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48
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Fischell SZ, Fischell JM, Olexa G, Callahan C, Bollinger ME. Impact of coronavirus disease 2019 pandemic on frequency and severity of asthma exacerbations in an inner-city population. Ann Allergy Asthma Immunol 2021; 128:322-324. [PMID: 34923126 PMCID: PMC8674655 DOI: 10.1016/j.anai.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 12/03/2021] [Accepted: 12/09/2021] [Indexed: 11/27/2022]
Affiliation(s)
| | - Jonathan M Fischell
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland
| | - Gloribel Olexa
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, Maryland
| | - Charles Callahan
- Population Health, University of Maryland Medical Center, Baltimore, Maryland
| | - Mary E Bollinger
- Division of Pediatric Pulmonology/Allergy & Immunology, University of Maryland School of Medicine, Baltimore, Maryland
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Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated with Pediatric Intensive Care Use for Life-threatening Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:981-991.e1. [PMID: 34775118 DOI: 10.1016/j.jaip.2021.10.065] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Social determinants of health are associated with asthma prevalence and healthcare use in children with asthma, but are multifactorial and complex. Whether social determinants similarly influence exacerbation severity is not clear. OBJECTIVE Composite measures of social determinants of health and readmission outcomes were evaluated in a large regional cohort of 1,403 school-age children admitted to a pediatric intensive care unit (PICU) for asthma. METHODS Residential addresses were geocoded and spatially joined to census tracts. Composite measures of social vulnerability and childhood opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots, where PICU admission rates per 1,000 children are at or above the 90th percentile, versus non-hot spots. RESULTS A total of 228 children resided within a neighborhood hot spot (16%). Hot spots were associated with a higher (ie, poorer) composite Social Vulnerability Index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a lower (ie, poorer) composite Childhood Opportunity Index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower childhood opportunity were associated with PICU readmission. Residing within a hot spot was further associated with a longer duration of hospital stay, individual inpatient bed days, and total census tract inpatient bed days. CONCLUSIONS Social determinants of health identified by geospatial analyses are associated with more severe asthma exacerbation outcomes in children. Outpatient strategies that address both biological and social determinants of health are needed to care for and prevent PICU admissions optimally in children with asthma.
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Cook Q, Argenio K, Lovinsky-Desir S. The impact of environmental injustice and social determinants of health on the role of air pollution in asthma and allergic disease in the United States. J Allergy Clin Immunol 2021; 148:1089-1101.e5. [PMID: 34743831 DOI: 10.1016/j.jaci.2021.09.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 02/07/2023]
Abstract
There is clear evidence that exposure to environmental air pollution is associated with immune dysregulation, asthma, and other allergic diseases. However, the burden of air pollution exposure is not equally distributed across the United States. Many social and environmental factors place communities of color and people who are in poverty at increased risk of exposure to pollution and morbidity from asthma and allergies. Here, we review the evidence that supports the relationship between air pollution and asthma, while considering the social determinants of health that contribute to disparities in exposures and outcomes.
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Affiliation(s)
- Quindelyn Cook
- Division of Pediatric Pulmonary and Allergy, Department of Pediatrics, Boston University School of Medicine, Boston, Mass
| | - Kira Argenio
- Division of Pediatric Pulmonology, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Stephanie Lovinsky-Desir
- Division of Pediatric Pulmonology, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY.
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