Relationship between pediatric primary provider visits and acute asthma ED visits

Risk Factors for Nonattendance Among Children With Asthma: A Systematic Review and Meta-Analysis

BACKGROUND

Nonattendance at scheduled outpatient visits among children with asthma has been associated with an increased risk of acute asthma events and increased health care expenses. Specific risk factors for nonattendance have been suggested, but a comprehensive overview is lacking.

OBJECTIVE

To investigate risk factors for nonattendance among children with asthma and assess whether nonattendance associates with acute events through a systematic review and meta-analysis.

METHODS

The study (PROSPERO: CRD42023471893) was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines using the PubMed, Ovid MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases and search terms "asthma/wheeze," "child," and "nonattendance." Original peer-reviewed studies in English were included and evaluated for risk of bias using the Newcastle Ottawa scale. A meta-analysis was performed for all risk factors. Finally, we analyzed whether nonattendance was associated with the risk of acute events.

RESULTS

A total of 17 studies encompassing 27,023 children with asthma were included. The meta-analysis was performed on 11 eligible studies, with 25,948 children, and identified the following risk factors for nonattendance; teenage versus preteen (odds ratio [OR] 1.26; 95% confidence interval [95% CI] 1.06-1.49; P < .01), non-White versus White ethnicity (OR 1.51; 95% CI 1.04-2.18; P = .03) and lower disease severity (OR 1.41; 95% CI 1.13-1.77; P < .01). There were no significant findings in the meta-analysis for insurance status, atopy, sex, or rural residence. Nonattendance associated with an increased risk of acute asthma events (OR 1.11; 95% CI 1.07-1.16; P < .01).

CONCLUSIONS

This systematic review and meta-analysis identified specific risk factors to facilitate the development of a strategy against nonattendance for pediatric patients with asthma. This is particularly important given nonattendance being associated with an increased risk of acute asthma.

Development and Validation of the Asthma Exacerbation Risk Score Using Claims Data

OBJECTIVE

Pediatric asthma is a costly and complex disease with proven interventions to prevent exacerbations. Finding the patients at highest risk of exacerbations is paramount given limited resources. Insurance claims identify all outpatient, inpatient, emergency, pharmacy, and diagnostic services. The objective was to develop a risk score indicating the likelihood of asthma exacerbation within the next year based on prior utilization.

METHODS

A retrospective analysis of insurance claims for patients 2 to 18 years in a network in Massachusetts with 3 years of continuous enrollment in a commercial plan. Thirty-six potential predictors of exacerbation in the third year were assessed with a stepwise regression. Retained predictors were weighted relative to their contribution to asthma exacerbation risk and summed to create the Asthma Exacerbation Risk (AER) score.

RESULTS

In a cohort of 28,196 patients, there were 10 predictors associated with the outcome of having an asthma exacerbation in the next year that depend on age, meeting the Healthcare Effectiveness Data and Information Set persistent asthma criteria, fill patterns of asthma medications and oral steroids, counts of nonexacerbation outpatient visits, an exacerbation in the last 6 months, and whether spirometry was performed. The AER score is calculated monthly from a claims database to identify potential patients for an asthma home-visiting program.

CONCLUSIONS

The AER score assigns a risk of exacerbation within the next 12 months using claims data to identify patients in need of preventive services.

Allergic Comorbidity Is a Risk Factor for Not Attending Scheduled Outpatient Visits in Children with Asthma

Asthma is one of the most common chronic diseases in children globally. Previous studies have shown that not attending asthma primary care consultations is associated with poorer treatment adherence and increased risk of loss of asthma control on a short-term basis. Here, we investigated long-term patterns and predictors of not attending scheduled asthma outpatient visits during 5-years of follow-up in 146 children with asthma. Of the 146 children, 67 (46%) did not attend at least one scheduled appointment, amounting to a total of 122 (10.8%) missed of 1133 scheduled appointments. In a multivariate analysis adjusting for total scheduled visits in the 5-year period any allergic sensitization was a significant risk factor for not attending ≥1 scheduled appointment (aOR = 6.6 (95% CI, 1.3–39.7), p = 0.03), which was not the case for asthma treatment step or lung function. Furthermore, atopic predisposition decreased the risk of non-attendance (aOR = 0.36 (0.13–0.92), p = 0.04). We found no association between non-attendance, treatment adherence or loss of asthma control. This study highlights that allergic comorbidity, but not degree of asthma severity, identifies a group of children with asthma who are prone to not attend scheduled outpatient appointments.

Reduced pediatric urgent asthma utilization and exacerbations during the COVID-19 pandemic

The COVID-19 pandemic has had a profound impact on healthcare access and utilization, which could have important implications for children with chronic diseases, including asthma. We sought to evaluate changes in healthcare utilization and outcomes in children with asthma during the COVID-19 pandemic. We used electronic health records data to evaluate healthcare use and asthma outcomes in 3959 children and adolescents, 5-17 years of age, with a prior diagnosis of asthma who had a history of well-child visits and encounters within the healthcare system. We assessed all-cause healthcare encounters and asthma exacerbations in the 12-months preceding the start of the COVID-19 pandemic (March 1, 2019-February 29, 2020) and the first 12 months of the pandemic (March 1, 2020-February 28, 2021). All-cause healthcare encounters decreased significantly during the pandemic compared to the preceding year, including well-child visits (48.1% during the pandemic vs. 66.6% in the prior year; p < .01), emergency department visits (9.7% vs. 21.0%; p < .01), and inpatient admissions (1.6% vs. 2.5%; p < .01), though there was over a 100-fold increase in telehealth encounters. Asthma exacerbations that required treatment with systemic steroids also decreased (127 vs. 504 exacerbations; p < .01). Race/ethnicity was not associated with changes in healthcare utilization or asthma outcomes. The COVID-19 pandemic corresponded to dramatic shifts in healthcare utilization, including increased telehealth use and improved outcomes among children with asthma. Social distancing measures may have also reduced asthma trigger exposure.

Specialist Care in Individuals With Asthma Who Required Hospitalization: A Retrospective Population-Based Study

BACKGROUND

Patients who are at risk for severe asthma exacerbations should receive specialist care. However, the care pattern for such patients in the real world is unclear.

OBJECTIVE

To describe the pattern of care among individuals with asthma who required hospitalization, and to identify factors associated with receiving asthma specialist care.

METHODS

This was a retrospective population-based study using health administrative data from two Canadian provinces. Individuals aged 14 to 45 years who were newly diagnosed with asthma between 2006 and 2016 and had at least one hospitalization for asthma at or within 5 years after the initial asthma diagnosis were included. First, we calculated frequencies of primary and specialist care around the asthma diagnosis: 1 year before and 2 years after in a 6-month period. Next, among individuals diagnosed with asthma by a primary care physician, we used multivariable Cox regressions to identify factors associated with receiving specialist care.

RESULTS

For 1862 individuals included, we found that most (≥71% per time period) were cared for by primary care physicians 1 year before and 2 years after the asthma diagnosis; the percentage of individuals seen at least once by a specialist for asthma and/or asthma-related respiratory conditions during the first 6 months since the diagnosis did not exceed 40%. Among 1411 of 1862 individuals who were under primary care before the asthma diagnosis (76%), controlling for covariates, living in a rural area or a low-income neighborhood was associated with less likelihood of receiving specialist care.

CONCLUSIONS

Despite recommendations, more than half of individuals with asthma who required hospitalization did not receive specialist care during the first 2 years since the diagnosis. Identified factors associated with receiving asthma specialist care suggested that access is an important barrier to receiving recommended care.

A Pilot Study of a Measure of Parental Trust in Pediatric Emergency Department Care Teams

OBJECTIVE

To modify and test an existing measure of trust validated in a primary care setting for use in a pediatric emergency department (PED).

METHODS

The study population was parents/guardians who brought their child to an urban PED with a chief complaint of abdominal pain or head injury. We used a 2-phase design with modifications resulting from cognitive interviews with 15 participants followed by a field test with 150 participants. We measured usefulness by percent missing responses and ceiling effects. Cronbach's alpha and greatest lower bound measured reliability. As evidence of validity, we calculated a total trust score by summing the item scale values and correlating the score with measures of constructs shown to be positively associated with trust in other settings. We conducted a similar analysis to test a published shortened version of the same scale.

RESULTS

Four items were modified prior to field testing. Ceiling effects for each item ranged from 53% to 67%. Missing data were minimal affecting only 2 items. The modified measure exhibited high reliability (Cronbach's alpha = .88, greatest lower bound = 0.93). Total trust scores ranged from 27 to 50 with mean (standard deviation) = 45.1 (4.9). The trust score exhibited a high positive correlation with communication and overall satisfaction, and moderate correlation with intent to adhere to physician recommendations. The short version of the scale performed similarly.

CONCLUSIONS

This study provides evidence that the modified Wake Forest measure of trust is applicable and useful in the PED setting for this patient population.

Well-Child Care Attendance and Risk of Asthma Exacerbations

BACKGROUND

Asthma remains a leading cause of hospitalization in US children. Well-child care (WCC) visits are routinely recommended, but how WCC adherence relates to asthma outcomes is poorly described.

METHODS

We conducted a retrospective longitudinal cohort study using electronic health records among 5 to 17 year old children residing in Durham County with confirmed asthma and receiving primary care within a single health system, to compare the association between asthma exacerbations and previous WCC exposure. Exacerbations included any International Classification of Diseases, Ninth Revision, or International Classification of Diseases, 10th Revision, coded asthma exacerbation encounter with an accompanying systemic glucocorticoid prescription. Exacerbations were grouped by severity: ambulatory encounter only, urgent care, emergency department, hospital encounters <24 hours, and hospital admissions ≥24 hours. In the primary analysis, we assessed time to asthma exacerbation based on the presence or absence of a WCC visit in the preceding year using a time-varying covariate Cox model.

RESULTS

A total of 5656 children met eligibility criteria and were included in the primary analysis. Patients with the highest WCC visit attendance tended to be younger, had a higher prevalence of private insurance, had greater asthma medication usage, and were less likely to be obese. The presence of a WCC visit in the previous 12 months was associated with a reduced risk of all-cause exacerbations (hazard ratio: 0.90; 95% confidence interval: 0.83-0.98) and severe exacerbations requiring hospital admission (hazard ratio: 0.53; 95% confidence interval: 0.39-0.71).

CONCLUSIONS

WCC visits were associated with a lower risk of subsequent severe exacerbations, including asthma-related emergency department visits and hospitalizations. Poor WCC visit adherence predicts pediatric asthma morbidity, especially exacerbations requiring hospitalization.

Association between adherence and severe asthma exacerbation: A systematic review and meta-analysis

OBJECTIVE

To assess the association between adherence levels and severe asthma exacerbation.

DESIGN

A systematic search was performed from inception to November 2018 on the following databases: PubMed, CENTRAL, EMBASE, and ClinicalTrials.gov.

SETTING AND PARTICIPANTS

Randomized-controlled trials (RCTs) and cohort and case-control studies that investigated the impact of adherence to controller medications on severe asthma exacerbation were included in the analysis. Data extraction was undertaken by 2 reviewers, and all studies were assessed for their qualities using the Cochrane risk of bias tool for RCT and the Newcastle-Ottawa scale for cohort and case-control studies. Random-effects model meta-analyses were performed.

OUTCOME MEASURES

Severe asthma exacerbation.

RESULTS

From 8061 articles, 8 studies were included in quantitative synthesis. The meta-analyses revealed that the odds of exacerbation among the patients with 80% or more adherence were lowered by 47% (odds ratio 0.53 [95% CI 0.42-0.66], P < 0.001) compared with less than 80%. When compared with less than 20% adherence, a 33% reduction in the odds (0.67 [0.53-0.86], P = 0.001) was associated with the patients achieving 50% or more, whereas a decrease in exacerbation was not associated with 20% to 49% adherence (0.94 [0.85-1.04], P = 0.22). In addition, a 2.4-fold increase in the odds (2.4 [2.1-2.7], P < 0.001) was associated with discontinuation of therapy.

CONCLUSION

The highest reduction in the odds of exacerbation was associated with patients achieving 80% or more adherence, and the odds also reduced among those with 50% or more adherence, whereas a substantial increase in exacerbation was associated with discontinuation of therapy.

Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study

Background

It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients.

Methods

This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions.

Result

A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001).

Conclusions

Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4300-1) contains supplementary material, which is available to authorized users.

Family Caregiver Marginalization is Associated With Decreased Primary and Subspecialty Asthma Care in Head Start Children

BACKGROUND

Urban minority children are at risk for poor asthma outcomes and might not receive appropriate primary or subspecialty care. We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma.

METHODS

The Barriers to Care Questionnaire (BCQ) is used to measure expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control using the Test for Respiratory and Asthma Control in Kids and these outcomes: PCP visits for asthma in the past 6 months, subspecialty care (allergist or pulmonologist) in the past 2 years, and ED visits in the past 3 months.

RESULTS

Three hundred ninety-five caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent (n = 236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (odds ratio [OR], 0.95; P = .014) and subspecialty visits (OR, 0.92; P = .019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR, 0.98; P = .027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes.

CONCLUSIONS

Among low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the health care system (marginalization). Clinicians who serve at-risk populations should be sensitive to families' past experiences and should consider designing interventions to target the most commonly reported barriers.

A missed primary care appointment correlates with a subsequent emergency department visit among children with asthma

OBJECTIVE

Since the Affordable Care Act's implementation, emergency department (ED) visits have increased. Poor asthma control increases the risk of acute exacerbations and preventable ED visits. The Centers for Medicare and Medicaid Services support the reduction of preventable ED visits to reduce healthcare spending. Implementation of interventions to avoid preventable ED visits has become a priority for many healthcare systems yet little data exist examining children's missed asthma management primary care (PC) appointments and subsequent ED visits.

METHODS

Longitudinal, retrospective review at a children's hospital was conducted for children with diagnosed asthma (ICD-9 493.xx), ages 2-18 years, scheduled for a PC visit between January 1, 2010, and June 30, 2012 (N = 3895). Records were cross-referenced with all asthma-related ED visits from January 1, 2010 to December 31, 2012. Logistic regression with maximum likelihood estimation was conducted.

RESULTS

None of the children who completed a PC appointment experienced an ED visit in the subsequent 6 months whereas 2.7% of those with missed PC appointments had an ED visit (χ2 = 64.28, p <.0001). Males were significantly more likely to have an ED visit following a missed PC appointment than females (χ2 = 34.37, p <.0001). There was a statistically significant interaction of sex × age. Younger children (<12 years) made more visits than older children.

CONCLUSIONS

The importance of adherence to PC appointments for children with asthma as one mechanism for preventing ED visits was demonstrated. Interventions targeting missed visits could decrease asthma-related morbidity, preventable ED visits, and healthcare costs.

Reducing emergency department visits utilizing a primary care asthma specialty clinic in a high-risk patient population

OBJECTIVE

Asthma is a leading cause of pediatric emergency department (ED) use. Optimizing asthma outcomes is a goal of Nationwide Children's Hospital (NCH) and its affiliated Accountable Care Organization. NCH's Primary Care Network, comprised of 12 offices serving a predominantly Medicaid population, sought to determine whether an Asthma Specialty Clinic (ASC) operated within a single primary care office could reduce ED asthma rates and improve quality measures, relative to all other network offices.

METHODS

An ASC was piloted with four components: patient monitoring, provider continuity, standardized assessment, and multi-disciplinary education. A registry was established to contact patients at recommended intervals. At extended-length visits, a general pediatrician evaluated patients and a multi-disciplinary team provided education. Novel educational tools were utilized, guideline-based templates recorded and spirometry obtained. ED asthma rate, spirometry utilization, and controller fills by intervention office patients were compared to all other network offices before and after ASC initiation.

RESULTS

At baseline, asthma ED visits by intervention and usual care populations were similar (p = 0.43). After, rates were significantly lower for intervention office patients versus usual care office patients (p < 0.001), declining in the intervention population by 26.2%, 25.2%, and 31.8% in 2013, 2014, and 2015, respectively, from 2012 baseline, versus increases of 3.8%, 16.2%, and 9.5% in the usual care population. Spirometry completion, controller fills, and patients with favorable Asthma Medication Ratios significantly increased for intervention office patient relative to the usual care population.

CONCLUSIONS

A primary care-based asthma clinic was associated with a significant and sustainable reduction in ED utilization versus usual care. What's new: This study describes a comprehensive, multi-disciplinary, and innovative model for an asthma management program within the medical home that demonstrated a significant reduction in ED visits, an increase in spirometry utilization, and an increase in controller fills in a high-risk asthma population versus comparison group.

Asthma-related emergency department use: current perspectives

Asthma is one of the most common chronic pediatric diseases. Patients with asthma often present to the emergency department for treatment for acute exacerbations. These patients may not have a primary care physician or primary care home, and thus are seeking care in the emergency department. Asthma care in the emergency department is multifaceted to treat asthma patients appropriately and provide quality care. National and international guidelines exist to help drive clinical care. Electronic and paper-based tools exist for both physicians and patients to help improve emergency, home, and preventive care. Treatment of patients with asthma should include the acute exacerbation, long-term management of controller medications, and controlling triggers in the home environment. We will address the current state of asthma research in emergency medicine in the US, and discuss some of the resources being used to help provide a medical home and improve care for patients who suffer from acute asthma exacerbations.

Increased identification of the primary care provider as the main source of asthma care among urban minority children

OBJECTIVE

Urban, minority, and disadvantaged youth with asthma frequently use emergency departments (EDs) for episodic asthma care instead of their primary care providers (PCPs). We sought to increase the rate of guardians' identification of the PCP as the source of asthma care for their children through integrated electronic health records and care coordination.

METHODS

In this prospective cohort study, we implemented an electronic communication process between an asthma specialty clinic and PCPs coupled with short-term care coordination in sample of youth aged 2-12 years with asthma and surveyed their guardians at baseline and 3 and 6 months after the intervention.

RESULTS

Guardians of 50 children (median age 5.8 years, 64% male, 98% African American, 94% public insurance) were enrolled. Compared to baseline, at 3 and 6 months after the intervention, significantly more guardians reported that the PCP was their child's primary asthma health care provider [70% at baseline, 85% at 3 months, 83% at 6 months (time averaged adjusted OR 77.4, 95% CI 3.0, 2027.1]. Further, significantly more guardians reported that they took their child to the PCP when the child experienced problems with his/her asthma [16% at baseline, 35% at 3 months, 41% at 6 months (time averaged adjusted odds ratio (OR) 10.6, 95% CI 2.7, 41.7].

CONCLUSION

Care in a subspecialty asthma clinic augmented by electronic communication with PCPs and short term care coordination was associated with significantly improved identification of PCPs as the primary source of asthma care in a cohort of urban minority youth.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

OBJECTIVE

The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008-10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis.

RESULTS

Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18-20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes.

CONCLUSIONS

Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Practice Variation in Management of Childhood Asthma Is Associated with Outcome Differences

BACKGROUND

Although specialist asthma care improves children's asthma outcomes, the impact of primary care management is unknown.

OBJECTIVE

To determine whether variation in preventive and acute care for asthma in pediatric practices affects patients' outcomes.

METHODS

For 22 practices, we aggregated 12-month patient data obtained by chart review and parent telephone interviews for 948 children, 3 to 12 years old, diagnosed with asthma to obtain practice-level measures of preventive (≥1 asthma maintenance visit/year) and acute (≥1 acute asthma visit/year) asthma care. Relationships between practice-level measures and individual asthma outcomes (symptom-free days, parental quality of life, emergency department [ED] visits, and hospitalizations) were explored using generalized estimating equations, adjusting for seasonality, specialist care, Medicaid insurance, single-family status, and race.

RESULTS

For every 10% increase in the proportion of children in the practice receiving preventive care, symptom-free days per child increased by 7.6 days (P = .02) and ED visits per child decreased by 16.5% (P = .002), with no difference in parental quality of life or hospitalizations. Only the association between more preventive care and fewer ED visits persisted in adjusted analysis (12.2% reduction; P = .03). For every 10% increase in acute care provision, ED visits per child and hospitalizations per child decreased by 18.1% (P = .02) and 16.5% (P < .001), respectively, persisting in adjusted analyses (ED visits 8.6% reduction, P = .02; hospitalizations 13.9%, P = .03).

CONCLUSIONS

Children cared for in practices providing more preventive and acute asthma care had improved outcomes, both impairment and risk. Persistence of improved risk outcomes in the adjusted analyses suggests that practice-level interventions to increase asthma care may reduce childhood asthma disparities.

Adherence in childhood asthma: the elephant in the room

Adherence to inhaled steroids is suboptimal in many children with asthma and can lead to poor disease control. Many previous studies in paediatric populations have used subjective and inaccurate adherence measurements, reducing their validity. Adherence studies now often use objective electronic monitoring, which can give us an accurate indication of the extent of non-adherence in children with asthma. A review of the studies using electronic adherence monitoring shows that half of them report mean adherence rates of 50% or below, and the majority report rates below 75%. Reasons for non-adherence are both intentional and non-intentional, incorporating illness perceptions, medication beliefs and practical adherence barriers. Interventions to improve adherence in the paediatric population have had limited success, with the most effective containing both educational and behavioural aspects.

Effectiveness of an asthma quality improvement program designed for maintenance of certification

OBJECTIVE

Pediatricians are required to perform quality improvement for board recertification. We developed an asthma project within the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, designed to meet recertification requirements and improve asthma care.

METHODS

The program was based on the learning collaborative model. We developed practice-based registries of children 5 to 17 years of age with persistent asthma and helped physicians improve processes of asthma care through education, data feedback, and sharing of best practices.

RESULTS

Fifty-six physicians participated in 3 cohorts; 594 patients were included in the project. In all cohorts, improvements occurred in the use of asthma action plans (62.4%-76.8% cohort 1, 50.6%-88.4% cohort 2, 53.0%-79.6% cohort 3) and Asthma Control Tests (4.6%-55.2% cohort 1, 9.0%-67.8% cohort 2, 15.2%-61.4% cohort 3). Less consistent improvements were observed in seasonal influenza vaccines, controller medications, and asthma follow-up visits. The proportion of patients experiencing ≥1 asthma exacerbation within the year declined in all 3 cohorts (37.8%-19.9%, P = .0002 cohort 1; 27.8%-20.7%, P = .1 cohort 2; 36.6%-26.9%, P = .1 cohort 3). For each cohort, asthma exacerbations declined to a greater extent than those of a comparison group.

CONCLUSIONS

This asthma quality improvement project designed for maintenance of certification improved processes of care among patients with persistent asthma. The learning collaborative approach may be a useful model for other board-recertification quality improvement projects but requires a substantial investment of organizational time and staff.

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children

OBJECTIVES

To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children.

METHODS

We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP.

RESULTS

One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06).

CONCLUSIONS

Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.

Examining household asthma management behavior through a microeconomic framework

National guidelines on the effective management of pediatric asthma have been promoted for over 20 years, yet asthma-related morbidity among low-income children remains disproportionately high. To date, household and clinical interventions designed to remediate these differences have been informed largely by a health behavior framework. However, these programs have not resulted in consistent sustained improvements in targeted populations. The continued funding and implementation of programs based on the health behavior framework leads us to question if traditional behavioral models are sufficient to understand and promote adaptation of positive health management behaviors. We introduce the application of the microeconomic framework to investigate potential mechanisms that can lead to positive management behaviors to improve asthma-related morbidity. We provide examples from the literature on health production, preferences, trade-offs and time horizons to illustrate how economic constructs can potentially add to understanding of disease management. The economic framework, which can be empirically observed, tested, and quantified, can explicate the engagement in household-level activities that would affect health and well-being. The inclusion of a microeconomic perspective in intervention research may lead to identification of mechanisms that lead to household decisions with regard to asthma management strategies and behavior. The inclusion of the microeconomic framework to understand the production of health may provide a novel theoretical framework to investigate the underlying causal behavioral mechanisms related to asthma management and control. Adaptation of an economic perspective may provide new insight into the design and implementation of interventions to improve asthma-related morbidity in susceptible populations.

Medication adherence and health care utilization in pediatric chronic illness: a systematic review

BACKGROUND AND OBJECTIVE

Advanced understanding of modifiable predictors of health care use in pediatric chronic illness is critical to reducing health care costs. We examined the relationship between medication non-adherence and health care use in children and adolescents who have a chronic medical condition.

METHODS

A systematic review of articles by using PubMed, PsycINFO, and CINAHL was conducted. Additional studies were identified by searching reference sections of relevant manuscripts. Studies that tested the relationship between medication non-adherence and health care use (ie, hospitalizations, emergency department visits, outpatient visits) or cost in children and adolescents (mean age ≤18 years) who have a chronic medical condition were included. Extraction of articles was completed by using predefined data fields.

RESULTS

Ten studies met our inclusion criteria. Nine of the 10 studies reviewed (90%) demonstrated a relationship between medication non-adherence and increased health care use. The directionality of this relationship varied depending on the outcome variable of interest.

CONCLUSIONS

Medication non-adherence is related to increased health care use in children and adolescents who have a chronic medical condition and should be addressed in clinical care. Future studies should include randomized controlled trials examining the impact of adherence promotion efforts on health care use and costs.

Parental education on asthma severity in the emergency department and primary care follow-up rates

Asthma is the most prevalent chronic condition affecting children and a common chief complaint in emergency departments (EDs). We aimed to improve parents' understanding of their child's asthma severity on accessing our pediatric ED for an acute asthma exacerbation. A retrospective chart review was conducted to determine outpatient follow-up rates from our ED in 2010-2011. In an attempt to educate parents at ED discharge about their child's asthma severity at presentation, we included a visual severity scale on their discharge instructions. Postdischarge telephone interviews were completed to determine postintervention follow-up rates. Asthma follow-up rates at 1 week improved from 20.8% to 50% after intervention. This difference was statistically significant after controlling for age and clinical asthma score with logistic regression (P < .0001). Offering predischarge education about a child's initial asthma severity is a simple intervention that significantly improved follow-up rates for children seen in the ED for asthma exacerbation.

Correlation of care process measures with childhood asthma exacerbations

OBJECTIVE

We sought to define processes of pediatric asthma care identifiable through administrative data that correlate with asthma exacerbations for use in quality improvement.

METHODS

Commercially insured children aged 5 to 17 years from the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, with persistent asthma in 2008, 2009, or 2010 were identified. The correlations of various process measures with asthma exacerbations, defined as hospitalizations or emergency department visits for asthma or outpatient visits for asthma with an oral steroid prescription, were analyzed by using logistic regression.

RESULTS

Significant correlations were found between filling 0 vs ≥ 1 controller medications in all years (relative risk [RR] 3.35, 2.11, and 2.71 in 2008, 2009, and 2010, respectively) although only 4% of subjects overall filled no controller medications. The asthma medication ratio (controller prescriptions divided by total asthma prescriptions) was also associated with exacerbations, with the lowest 2 quartiles having a lower risk compared with the highest in all years (RR 2.27, 2.45, and 2.39 for the lowest; RR 2.10, 2.02, and 2.65 for the second quartile in 2008, 2009, and 2010, respectively).

CONCLUSIONS

Filling 0 vs ≥ 1 controllers and the asthma medication ratio correlated with asthma exacerbations. Although both might serve as quality improvement metrics for pediatric asthma, we favor the asthma medication ratio because it applies to a broader range of children with asthma and better reflects the recommended clinical approach for children with persistent asthma.

Follow-up care after an emergency department visit for asthma and subsequent healthcare utilization in a universal-access healthcare system

OBJECTIVES

To describe the follow-up care within 28 days of an emergency department (ED) visit for asthma and to determine the association of follow-up visits within 28 days with ED re-visits and hospital admissions in the subsequent year.

STUDY DESIGN

Population-based retrospective cohort study of children with asthma aged 2-17 years treated in an ED in Ontario, Canada between April 14, 2006 and February 28, 2009. Multiple linked health administrative datasets and Cox proportional hazard multivariable survival models were used to test the association of characteristics of 28-day follow-up visits with 1-year outcomes.

RESULTS

The final cohort consisted of 29391 children, of whom 32.8% had follow-up, 6496 (22.1%) had an ED re-visit, and 801 (2.7%) had a hospital admission. Having a follow-up visit was not associated with ED re-visit or hospitalizations (hazard ratio 0.98; 95% CI 0.93, 1.03 and hazard ratio 1.06; 95% CI 0.92, 1.23, respectively). Younger children and those with indices of more severe acute or chronic asthma were more likely to have ED re-visits and hospitalizations. Other follow-up care characteristics (number of visits, type of physician providing care) were not associated with outcomes.

CONCLUSIONS

Despite a universal healthcare setting, most children did not access follow-up care after an ED visit for asthma, and those that did had no associated benefit in terms of reduced ED re-visits and hospitalizations in the subsequent year.

Pediatric primary care services in Manitoba: is the health of the next generation of children at risk?

OBJECTIVES

Physician resource planning is an important part of health policy, but to date there are no studies measuring the primary care service needs of a particular population. The aim of this study was to project the expected provision of physician services for the pediatric population of one Canadian province for 2020.

METHODS

A novel standardized measure of physician service provision, the equivalent services measure, was developed using mathematical modeling. Population projections and past use of services were used to calculate the projected service needs for the pediatric population of Manitoba.

RESULTS

Despite projecting a small increase in the pediatric population (2.8%), our model predicted a decrease of 13.4% in the services that would be provided.

CONCLUSIONS

The findings of this study indicate that the health of future generations of children may be at risk. Further research is needed to determine the effect of the reduction in pediatric service provision on the health of the pediatric population.

A randomized controlled trial of parental asthma coaching to improve outcomes among urban minority children

OBJECTIVES

To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits.

DESIGN

Randomized controlled trial.

SETTING

Urban tertiary care children's hospital.

PARTICIPANTS

Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care.

INTERVENTION

Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group).

MAIN OUTCOME MEASURES

The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment.

RESULTS

We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27).

CONCLUSION

This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00149500.

Crime, neighborhood deprivation, and asthma: a GIS approach to define and assess neighborhoods

Exposure to neighborhood factors remains difficult to quantify when neighborhoods are often predefined and imprecisely measured. This study examines the association between neighborhood deprivation and participation in a community-based asthma case management (CM) program in Oakland, CA. We estimated neighborhoods by calculating walking distances of , and miles around each child's (n=2892) residence. The model assesses deprivation by the addition of weighted factors within a child's neighborhood-crime rates, alcohol outlets, and eight 2000 US Census characteristics. The results illustrate that neighborhood deprivation is weakly associated with greater levels of program participation, but neighborhood education level, measured by percentage of residents with less than a high school education, is strongly associated with greater program participation (OR: 4.43, 95% CI: [1.23, 15.99]). Neighborhood deprivation factors were significantly different between neighborhoods defined by walking distances and census blockgroups (Wilcoxon-signed rank test: p<0.05).

Relationship between presence of a reported medical home and emergency department use among children with asthma

This study examined data from the 2005-2006 National Survey of Children with Special Health Care Needs to assess the relationship among children with asthma between a reported medical home and emergency department (ED) use. The authors used 21 questions to measure 6 medical home components: personal doctor/nurse, family-centered, compassionate, culturally effective and comprehensive care, and effective care coordination. Weighted zero-inflated Poisson regression analyses assessed the independent effects of having a medical home on annual number of child ED visits while controlling for child and parental characteristics, and the differential likelihood of securing a medical home. Nearly half (49.9%) of asthmatic children had a medical home. Receiving primary care in a medical home was associated with fewer ED visits (incidence rate ratio = 0.93; 95% confidence interval = 0.89-0.97). A medical home in which physicians and parents share responsibility for ensuring that children have access to needed services may improve child and family outcomes for children with asthma.

Hyper-use of the ED

OBJECTIVES

This study aims to describe the population that averages one or more emergency department (ED) visits per month and compare them to the general ED population to determine if there are associated characteristics.

METHODS

A retrospective cohort study conducted in a teaching hospital between January 1, 2001, and December 31, 2004, identified all patients with more than 35 visits. This hyper-user (HU) cohort (n = 49) was compared to a randomly selected group of non-HU patients (n = 50) on the following measures: age, sex, insurance coverage, primary medical doctor (PMD), dwelling location, chief complaint, comorbidities, and disposition.

RESULTS

The HU group was significantly older (mean, 49.45 years) than the non-HU group (37.32 years) with a P < .0001. There was no difference between the groups in sex, insurance coverage, PMD, dwelling location, and disposition. A univariant logistical regression found that previous cardiovascular, genitourinary, or psychiatric disease were predictors of hyper-use.

CONCLUSIONS

The HU group is older and more likely to have a history of cardiovascular, genitourinary, and psychiatric disease but is similar to the non-HU group in other measured parameters. The HU group appears to have equal access to a PMD and is not more likely to be admitted to the hospital than the non-HU group.

State of childhood asthma and future directions conference: overview and commentary

The Merck Childhood Asthma Network, Inc conference titled "State of Childhood Asthma and Future Directions: Strategies for Implementing Best Practices" was held December 13 to 14, 2006. Here we summarize the presentations and recommendations for systems approaches from that conference and discuss current asthma care.

Rural health disparities in asthma care and outcomes

Fifty-nine million Americans (21% of the US population) live in rural areas of the United States. Compared with persons living in urban areas of the United States, rural populations have lower income, a higher rate of government versus private insurance, and decreased access to health care. Although there are reports of lower asthma prevalence in rural areas, the majority of these data have been published on international populations, with few available studies looking at American urban versus rural asthma prevalence on a national scale or comparing rural with nearby urban cohorts in the United States. A large body of literature, mainly generated from studies of rural Europe, suggests that lower prevalence might be due to beneficial effects of exposure to farm environments, but the extent to which this applies to the rural United States, where a smaller proportion of the population engages in farming, is unclear. The United States has the additional covariate of having a higher proportion of African Americans, who have a greater asthma burden than whites independent of socioeconomic status, clustered in cities. There are data indicating that rural patients have increased difficulty obtaining health care in general and limited data suggesting that they receive inferior care for asthma. Future work is needed to more clearly define asthma prevalence and morbidity among residents of the rural United States, as well as to identify interventions effective in this population.

The effect of violence on asthma: are our children facing a double-edged sword?

Low income, urban children with asthma are experiencing community violence that may contribute to asthma morbidity. The objective of this study was to examine the relationship between caregiver report of feeling unsafe, seeing community violence or child seeing community violence and asthma morbidity and health care utilization. Two hundred thirty-one caregivers of children with asthma enrolled in an asthma,education, intervention reported perceptions of safety and violence exposure in six months and frequency of child asthma symptoms, emergency department (ED), primary care (PCP) visits and hospitalizations over 12 months. Children were primarily male (93%), black (61%), and reported income <$30,000 (56%). Violence exposure was high: feeling unsafe (25%), seeing violence themselves (22%), child saw violence (14%). If caregivers or children saw violence, there were significantly more nighttime symptoms than those who were not exposed (caregiver: yes violence = 6.72 +/- 9.19, no violence = 4.23 +/- 6.98, P = 0.03; child: yes violence = 7.09 +/- 7.15, no violence = 4.37 +/- 9.49, P = 0.05). Children who saw violence were less likely to see their PCP. Families exposed to community violence report more asthma symptoms, but are less likely to seek care for asthma. Health care providers and asthma educators should evaluate potential violence exposure with asthma patients and tailor care and education to include violence prevention and avoidance.