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Allen ED, Montgomery T, Ayres G, Cooper J, Gillespie J, Gleeson SP, Groner J, Hersey S, McGwire G, Rowe C, Snyder D, Stukus D, Stukus KS, Timan C, Wegener N, Brilli RJ. Quality Improvement-Driven Reduction in Countywide Medicaid Acute Asthma Health Care Utilization. Acad Pediatr 2019; 19:216-226. [PMID: 30597287 DOI: 10.1016/j.acap.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 12/21/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study evaluates the impact of a coordinated effort by an urban pediatric hospital and its associated accountable care organization to reduce asthma-related emergency department (ED) and inpatient utilization by a large, countywide Medicaid patient population. METHODS Multiple evidence-based interventions targeting general pediatric asthma care and high health care utilizers were implemented using standardized quality improvement methodologies. Annual asthma ED and inpatient utilization rates by 2- to 18-year-old members of an accountable care organization living in the surrounding county (>140,000 eligible members in 2016), adjusted per 1000 children from 2008 through 2016, were analyzed using Poisson regression. We compared these ED utilization rates to national rates from 2006 to 2014. RESULTS Asthma ED utilization fell from 18.1 to 12.9 visits/1000 children from 2008 to 2016, representing a 28.7% reduction, with an average annual decrease of 3.9% (P < .001), during a time when national utilization was increasing. Asthma inpatient utilization did not change significantly during the study period. CONCLUSIONS Asthma-related ED utilization was significantly reduced in a large population of primarily urban, minority, Medicaid-insured children by implementing a multimodal asthma quality improvement program. With adequate support, a similar approach could be successful in other communities.
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Affiliation(s)
- Elizabeth D Allen
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio.
| | - Tricia Montgomery
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Gloria Ayres
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Jennifer Cooper
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Joshua Gillespie
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Sean P Gleeson
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio; Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Judith Groner
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Stephen Hersey
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Gerd McGwire
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Courtney Rowe
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Dane Snyder
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - David Stukus
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Kristin S Stukus
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Christopher Timan
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Neal Wegener
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
| | - Richard J Brilli
- Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio
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Bair-Merritt MH, Voegtline K, Ghazarian SR, Granger DA, Blair C, Johnson SB. Maternal intimate partner violence exposure, child cortisol reactivity and child asthma. CHILD ABUSE & NEGLECT 2015; 48:50-7. [PMID: 25435104 PMCID: PMC4446253 DOI: 10.1016/j.chiabu.2014.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 10/31/2014] [Accepted: 11/04/2014] [Indexed: 05/11/2023]
Abstract
Psychosocial stressors like intimate partner violence (IPV) exposure are associated with increased risk of childhood asthma. Longitudinal studies have not investigated the role of hypothalamic-pituitary-adrenal (HPA) axis reactivity (and associated alterations in cortisol release) in the child IPV exposure-asthma association. We sought to investigate this association, and to assess whether this relationship differs by child HPA reactivity. This secondary analysis used longitudinal cohort data from the Family Life Project. Participants included 1,292 low-income children and mothers; maternal interview and child biomarker data, including maternal report of IPV and child asthma, and child salivary cortisol obtained with validated stress reactivity paradigms, were collected when the child was 7, 15, 24, 35, and 48 months. Using structural equation modeling, maternal IPV when the child was 7 months of age predicted subsequent reports of childhood asthma (B=0.18, p=.002). This association differed according to the child's HPA reactivity status, with IPV exposed children who were HPA reactors at 7 and 15 months of age--defined as a ≥10% increase in cortisol level twenty minutes post peak arousal during the challenge tasks and a raw increase of at least .02μg/dl--being significantly at risk for asthma (7 months: B=0.17, p=.02; 15 months: B=0.17, p=.02). Our findings provide support that children who are physiologically reactive are the most vulnerable to adverse health outcomes when faced with environmental stressors.
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Affiliation(s)
- Megan H Bair-Merritt
- Division of General Pediatrics, Boston Medical Center, 88 East Newton Street, Vose 305, Boston, MA 02118, USA
| | - Kristin Voegtline
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Sharon R Ghazarian
- Johns Hopkins School of Medicine, 200 North Wolfe Street, Division of General Pediatrics, Baltimore, MD 21287, USA
| | - Douglas A Granger
- Institute for Interdisciplinary Salivary Bioscience Research, Arizona State University, 550 East Orange Street, Tempe, AZ 85287, USA; School of Nursing, Johns Hopkins, 525 North Wolfe Street, Baltimore, MD 21205, USA; Department of Applied Psychology, New York University, 246 Greene Street, New York, NY 10003, USA
| | - Clancy Blair
- Division of General Pediatrics, Boston Medical Center, 88 East Newton Street, Vose 305, Boston, MA 02118, USA; Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA; Johns Hopkins School of Medicine, 200 North Wolfe Street, Division of General Pediatrics, Baltimore, MD 21287, USA; Institute for Interdisciplinary Salivary Bioscience Research, Arizona State University, 550 East Orange Street, Tempe, AZ 85287, USA; School of Nursing, Johns Hopkins, 525 North Wolfe Street, Baltimore, MD 21205, USA; Department of Applied Psychology, New York University, 246 Greene Street, New York, NY 10003, USA
| | - Sara B Johnson
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA; Johns Hopkins School of Medicine, 200 North Wolfe Street, Division of General Pediatrics, Baltimore, MD 21287, USA
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