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Smith LB, O'Brien C, Kenney GM, Waidmann TA. Black-White Disparities in Asthma Hospitalizations and ED Visits Among Medicaid-Enrolled Children. Hosp Pediatr 2024; 14:490-498. [PMID: 38752291 DOI: 10.1542/hpeds.2023-007477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/17/2024] [Accepted: 01/25/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND AND OBJECTIVES Asthma is a common, potentially serious childhood chronic condition that disproportionately afflicts Black children. Hospitalizations and emergency department (ED) visits for asthma can often be prevented. Nearly half of children with asthma are covered by Medicaid, which should facilitate access to care to manage and treat symptoms. We provide new evidence on racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children. METHODS We used comprehensive Medicaid claims data from the Transformed Medicaid Statistical Information System. Our study population included 279 985 Medicaid-enrolled children with diagnosed asthma. We identified asthma hospitalizations and ED visits occurring in 2019. We estimated differences in the odds of asthma hospitalizations and ED visits for non-Hispanic Black versus non-Hispanic white children, adjusting for sex, age, Medicaid eligibility group, Medicaid plan type, state, and rurality. RESULTS In 2019, among Black children with asthma, 1.2% had an asthma hospitalization and 8.0% had an asthma ED visit compared with 0.5% and 3.4% of white children with a hospitalization and ED visit, respectively. After adjusting for other characteristics, the rates for Black children were more than twice the rates for white children (hospitalization adjusted odds ratio 2.45, 95% confidence interval 2.23-2.69; ED adjusted odds ratio 2.42; 95% confidence interval 2.33-2.51). CONCLUSIONS There are stark racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children with asthma. To diminish these disparities, it will be important to implement solutions that address poor quality care, discriminatory treatment in health care settings, and the structural factors that disproportionately expose Black children to asthma triggers and access barriers.
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Custer CM, O'Neil ER, Paskaradevan J, Rissmiller BJ, Gazzaneo MC. Children with Near-Fatal Asthma: The Use of Inhaled Volatile Anesthetics and Extracorporeal Membrane Oxygenation. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:170-173. [PMID: 36537704 DOI: 10.1089/ped.2022.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background and Purpose: The use of extracorporeal membrane oxygenation (ECMO) has been described for near-fatal asthma that continues to be refractory despite maximal medical therapy. Methods: Patients admitted to the pediatric intensive care unit at Texas Children's Hospital from 2012 to 2020 with the diagnosis of asthma who were supported on ECMO or isoflurane were included in the study. Patient demographics, medication usage, and complications were compared between the case group (ECMO, n = 12) and the control group (isoflurane only, n = 8). Results: All patients survived to discharge. ECMO patients received shorter durations of albuterol (12 versus 104 h, P = 0.0002) and terbutaline (13.3 versus 31.5 h, P = 0.0250). There were no differences in complication rates between the 2 groups. Conclusion: ECMO is a reasonable and safe support method for patients with near-fatal asthma and may lead to less bronchodilator medication exposure when compared with inhaled volatile anesthetic use.
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Affiliation(s)
- Chasity M Custer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Erika R O'Neil
- Department of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Brian J Rissmiller
- Department of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Maria C Gazzaneo
- Department of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA.,Department of Pulmonology, Baylor College of Medicine, Houston, Texas, USA
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Ramgopal S, Attridge M, Akande M, Goodman DM, Heneghan JA, Macy ML. Distribution of Emergency Department Encounters and Subsequent Hospital Admissions for Children by Child Opportunity Index. Acad Pediatr 2022; 22:1468-1476. [PMID: 35691534 DOI: 10.1016/j.acap.2022.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate differences in emergency department (ED) utilization and subsequent admission among children by Child Opportunity Index (COI). METHODS We performed a cross-sectional study of pediatric (<18 years) encounters to 194 EDs in Illinois from 2016 to 2020. Each encounter was assigned to quntiles of COI 2.0 by postal code. We described the difference in the percent of encounters between lower (Very Low and Low) and higher (Very High and High) COI overall and among diagnoses with overrepresentation from lower COI groups. We evaluated the association of diagnosis with COI in ordinal models adjusted for demographics. RESULTS There were 4,653,026 eligible ED encounters classified by COI as Very Low (28.6%), Low (24.8%), Moderate (20.3%), High (15.6%), and Very High (10.8%) (difference between low and high COI encounters 27.0%). Diagnoses with the greatest difference between low and high COI were eye infection, upper respiratory tract infections, and cough. The COI distribution for children admitted from the ED (n = 140,298) was 29.1% Very Low, 19.3% Low, 18.2% Moderate, 17.7% High, and 15.7% Very High (percent difference 15.1%). Diagnoses with the greatest differences between low and high COI among admitted patients were sickle cell crisis, asthma, and influenza. All ED diagnoses and 7/12 admission diagnoses were associated with lower COI in multivariable ordinal models. CONCLUSIONS Children from lower COI areas are overrepresented in ED and inpatient encounters overall and within certain diagnosis groups. Further research is required to examine how health outcomes may be influenced by the structural and contextual characteristics of a child's neighborhood.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (S Ramgopal, M Attridge, and ML Macy), Chicago, Ill.
| | - Megan Attridge
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (S Ramgopal, M Attridge, and ML Macy), Chicago, Ill
| | - Manzilat Akande
- Section of Critical Care, Oklahoma University Health Sciences Center (M Akande), Oklahoma, Okla
| | - Denise M Goodman
- Division of Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (DM Goodman), Chicago, Ill
| | - Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital; University of Minnesota (JA Heneghan), Minneapolis, Minn
| | - Michelle L Macy
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine (S Ramgopal, M Attridge, and ML Macy), Chicago, Ill; Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (ML Macy), Chicago Ill
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Halterman JS, Riekert KA, Fagnano M, Tremblay P, Blaakman S, Tajon R, Wang H, Borrelli B. Effect of the School-Based Asthma Care for Teens (SB-ACT) program on asthma morbidity: a 3-arm randomized controlled trial. J Asthma 2022; 59:494-506. [PMID: 33307900 PMCID: PMC8285039 DOI: 10.1080/02770903.2020.1856869] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Urban adolescents with asthma often have inadequate preventive care. We tested the effectiveness of the School-Based Asthma Care for Teens (SB-ACT) program on asthma morbidity and preventive medication adherence.Methods:Subjects/Setting- 12-16yr olds with persistent asthma in Rochester, NY schools. Design- 3-group randomized trial (2014-2019). SB-ACT Intervention- Two core components: 1) Directly observed therapy (DOT) of preventive asthma medications, provided in school for at least 6-8 weeks for the teen to learn proper technique and experience the benefits of daily preventive therapy; 2) 4-6 weeks later, 3 sessions of motivational interviewing (MI) to discuss potential benefits from DOT and enhance motivation to take medication independently. We included 2 comparison groups: 1) DOT-only for 6-8wks, and 2) asthma education (AE) attention control. Masked follow-up assessments were conducted at 3, 5, and 7mos. Outcomes- Mean number of symptom-free days (SFDs)/2 weeks and medication adherence. Analyses- Modified intention-to-treat repeated measures analysis.Results: We enrolled 430 teens (56% Black, 32% Hispanic, 85% Medicaid). There were no group differences at baseline. We found no difference in SFDs at any follow-up timepoint. More teens in the SB-ACT and DOT-only groups reported having a preventive asthma medication at each follow-up (p<.001), and almost daily adherence at 3 and 5-months (p<.001, p=.003) compared to AE. By 7 months there were no significant differences between groups in adherence (p=.49).Conclusion: SB-ACT improved preventive medication availability and short-term adherence but did not impact asthma symptoms. Further work is needed to create developmentally appropriate and effective interventions for this group.
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Affiliation(s)
- Jill S. Halterman
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester Medical Center
| | - Kristin A. Riekert
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University
| | - Maria Fagnano
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester Medical Center
| | - Paul Tremblay
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester Medical Center
| | | | - Reynaldo Tajon
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester Medical Center
| | - Honguye Wang
- Department of Biostatistics, School of Medicine and Dentistry, University of Rochester
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Yu J, Perrin JM, Hagerman T, Houtrow AJ. Underinsurance Among Children in the United States. Pediatrics 2022; 149:183780. [PMID: 34866156 PMCID: PMC9647940 DOI: 10.1542/peds.2021-050353] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES We describe the change in the percentage of children lacking continuous and adequate health insurance (underinsurance) from 2016 to 2019. We also examine the relationships between child health complexity and insurance type with underinsurance. METHODS Secondary analysis of US children in the National Survey of Children's Health combined 2016-2019 dataset who had continuous and adequate health insurance. We calculated differences in point estimates, with 95% confidence intervals (CIs), to describe changes in our outcomes over the study period. We used multivariable logistic regression adjusted for sociodemographic characteristics and examined relationships between child health complexity and insurance type with underinsurance. RESULTS From 2016 to 2019, the proportion of US children experiencing underinsurance rose from 30.6% to 34.0% (+3.4%; 95% CI, +1.9% to +4.9%), an additional 2.4 million children. This trend was driven by rising insurance inadequacy (24.8% to 27.9% [+3.1%; 95% CI, +1.7% to +4.5%]), which was mainly experienced as unreasonable out-of-pocket medical expenses. Although the estimate of children lacking continuous insurance coverage rose from 8.1% to 8.7% (+0.6%), it was not significant at the 95% CI (-0.5% to +1.7%). We observed significant growth in underinsurance among White and multiracial children, children living in households with income ≥200% of the federal poverty limit, and those with private health insurance. Increased child health complexity and private insurance were significantly associated with experiencing underinsurance (adjusted odds ratio, 1.9 and 3.5, respectively). CONCLUSIONS Underinsurance is increasing among US children because of rising inadequacy. Reforms to the child health insurance system are necessary to curb this problem.
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Affiliation(s)
- Justin Yu
- Departments of Pediatrics,Address correspondence to Justin Yu, MD, MS, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Faculty Pavilion, Suite 3110, 4401 Penn Ave, Pittsburgh, PA, 15224. E-mail:
| | - James M. Perrin
- Department of Pediatrics, Harvard Medical School and MassGeneral Hospital for Children, Boston, Massachusetts
| | - Thomas Hagerman
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Amy J. Houtrow
- Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Bynum M. Community Health Centers Primary Care Physicians' Asthma Management Perception of Uninsured Patients. Prof Case Manag 2021; 25:335-342. [PMID: 33017370 DOI: 10.1097/ncm.0000000000000406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF STUDY Explore the perceptions of primary care physicians (PCPs) from community health care centers (CHCs) in Franklin County, Ohio, regarding factors that contribute to their inability to consistently provide sustainable asthma management services to their uninsured patient population. PRIMARY PRACTICE SETTING Asthmatic patients are not consistently receiving sustainable asthma management in CHCs in Ohio. Primary care physicians in CHCs play a pivotal role in closing health care gaps for asthmatic patients. To minimize the barriers that impede the efforts of PCPs to control asthma for their uninsured patients, asthma disease management programs that include case management services in CHCs in Franklin County, Ohio, are needed. METHODOLOGY AND SAMPLE A convenience sample of 4 PCPs from 2 CHCs in Franklin County, Ohio, was interviewed face-to-face. Interviews, direct observation, and previously published research were the sources of data utilized for this study. RESULTS Results indicated that 75% of participants did not use standard guidelines while treating their patients. Physician time constraints and access to affordable medication were identified as some of the barriers to providing sustainable asthma management services. IMPLICATIONS FOR CASE MANAGEMENT Asthma is a complex chronic disease. Disease case managers not only are capable of coordinating health care services for a variety of patient populations but are also effective in managing complex diseases such as asthma for disadvantaged populations. Evidence-based case management models are needed to support PCPs in CHCs. Without the inclusion of asthma-specific case managers as part of the care delivery structure, CHCs may continue to provide subpar disease management services for uninsured asthmatic patients.
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Affiliation(s)
- Mary Bynum
- Mary Bynum, MA, BSN, RN, CCM, DHA, is the Department Chair for Healthcare Programs, Program Chair for the Healthcare Management Program, and Lead Faculty for the Public Administration Program at Franklin University. Dr. Bynum received her doctorate in Health Administration from the University of Phoenix. In addition, she holds a Master of Arts in Public Policy and Management and Bachelor of Science in Nursing from the Ohio State University. Dr. Bynum is a certified case manager and a registered nurse. She has an extensive background in operational excellence, project management, regulatory adherence, and health care policy. She has served more than 22 years in both the public and private sectors. Her research interests include vulnerable populations, health disparities, health policy, and social determinants of health. Dr. Bynum is a national speaker and wellness enthusiast. She is a member of Alpha Kappa Alpha Sorority, Incorporated, Franklin County Children Services Citizens Advisory Committee, Central Ohio Case Management Network, and Fort Hayes Metropolitan Education Center Health Science and Dental Hygiene Advisory Board and is the founder of the Legacy Group of Ohio. She is the recipient of the Stephan Shank award for Teaching Excellence. In addition, she is a marathon runner and fitness guru
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Fife Donney J, Mitchell SJ, Lewin A. Medicaid Instability and Mental Health of Teen Parent Families. FAMILY & COMMUNITY HEALTH 2020; 43:10-16. [PMID: 31764302 DOI: 10.1097/fch.0000000000000240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This study examines the effect of inconsistent Medicaid coverage on parenting stress, maternal depression, and child behavior in a sample of teen mothers and their children. The majority (54%) of mothers experienced inconsistent coverage. After 24 months, mothers experiencing inconsistent coverage had significantly higher parenting stress and depressive symptoms, and their children had more internalizing behaviors than families with consistent Medicaid. These differences existed despite no initial differences and controlling for numerous covariates. Policies and practices that stabilize Medicaid coverage for teen parent families may reduce unnecessary stress, depressive symptoms, and early childhood behavior problems.
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Affiliation(s)
- Julie Fife Donney
- Department of Family Science, School of Public Health, University of Maryland, College Park (Drs Donney and Lewin). Dr Mitchell is an Independent Research Consultant, Nashville, Tennessee
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8
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Caveney B, Fagnano M, Halterman JS, Frey SM. Identifying which children with persistent asthma have preventive medications available at home. J Asthma 2019; 57:1188-1194. [PMID: 31276430 DOI: 10.1080/02770903.2019.1640734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To compare caregiver-reported preventive medication use and pharmacy data with medications available at home for children with persistent asthma, and identify factors associated with having preventive medication at home.Methods: We analyzed baseline data from the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) study, including medication use, symptoms, and demographics. Research assistants documented all asthma medications available during home visits. We reviewed pharmacy records for a subset of children. Bivariate and multivariate analyses identified factors associated with having any preventive medication in the home.Results: We included 335 children (mean 7.7 years, 56% Black, 34% Hispanic, 77% Medicaid; participation 79%). Most caregivers (69%) reported preventive medication use, yet only 45% had preventive medication at home. Compared to families with preventive medication at home, more families without preventive medication reported discontinuous insurance in the prior year (7% vs. 15%, p = .02) and medication sharing (22% vs. 32%, p = .04). For the subset with pharmacy records (n = 192), 40% filled a preventive medication in the past year and 15% had a preventive medication at home. In multivariate analyses, children were less likely to have preventive medication at home when caregivers reported no preventive medication use in the past 2 weeks (OR 0.25; 95% CI 0.14, 0.43), discontinuous insurance (OR 0.42; 95% CI 0.19, 0.97), medication sharing (OR 0.54; 95% CI 0.32, 0.91), or caregiver education ≥ HS (OR 0.59; 95% CI 0.35, 0.99).Conclusion: Among urban children with persistent asthma, neither caregiver report nor pharmacy data reflect home preventive medication availability. Inquiring about insurance coverage and medication sharing may improve preventive medication availability for these children.
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Affiliation(s)
- Brennen Caveney
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Maria Fagnano
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Jill S Halterman
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Sean M Frey
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
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9
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The impact of urban street tree species on air quality and respiratory illness: A spatial analysis of large-scale, high-resolution urban data. Health Place 2019; 56:80-87. [PMID: 30711775 DOI: 10.1016/j.healthplace.2019.01.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 11/24/2022]
Abstract
Urban trees play a key role in reducing greenhouse gas emissions, cleaning air, promoting physical activity, and improving mental health. However, it is still largely unknown how the density and species of urban street trees may impact local public health. This study demonstrates how open data mining and large-scale spatial data integration can contribute to deeper insights into the effects of urban forestry. We analyze the impact of the spatial distribution of street trees by species in New York City by combining crowd-sourced tree census data - which includes geolocation, species, size, and condition for each of 652,169 street trees - with pollen activity, allergen severity, land use, housing conditions, and neighborhood demographic data. We further integrate neighborhood asthma hospitalization and emergency department visit rates and air quality data (PM2.5) to investigate how street trees impact local air quality and the prevalence of acute respiratory illness. Using a geographically weighted regression model, the results indicate that although a greater concentration of trees contributes to better local air quality, species with severe allergenicity can increase local asthma hospitalization rates in vulnerable populations, controlling for other covariates.
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10
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Pan IW, Lam S, Clarke DF, Shih YCT. Insurance transitions and healthcare utilization for children with refractory epilepsy. Epilepsy Behav 2018; 89:48-54. [PMID: 30384099 DOI: 10.1016/j.yebeh.2018.09.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/27/2018] [Accepted: 09/27/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of the study is to investigate the association between insurance transitions and healthcare utilization among children with refractory epilepsy. METHODS We applied published algorithms to identify the study cohort of children with a diagnosis of refractory epilepsy who were treated between 10/1/2013 and 9/30/2014 at 36 children's hospitals in the United States. Insurance transition was defined as having any change in the type of primary payer from the first date of diagnosis to the date of the last visit at the same hospital. Univariate and multilevel multivariable analytical methods were used in the study. RESULTS Among 3488 children hospitalized with refractory epilepsy, rates of insurance transitions at 1, 2, and 5 years of refractory epilepsy diagnosis were 8.1%, 14%, and 29.9%, respectively. Patients whose primary payer at diagnosis was Private or Others were more likely to experience insurance transitions than patients whose primary payer was Medicaid. Younger children were associated with a higher risk of insurance transitions than older children. The high intensity of insurance transitions was associated with a higher number of emergency department and inpatient visits. CONCLUSIONS Insurance transitions interrupted the continuity of medical care for children with refractory epilepsy and were associated with more frequent hospitalizations and emergency department visits, which then translated to higher healthcare costs. Medicaid provided stable insurance coverage and is critically important for these patients and should be the main focus for policies aiming to minimize insurance transitions and optimize healthcare delivery.
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Affiliation(s)
- I-Wen Pan
- Baylor College of Medicine, Department of Neurosurgery, 7200 Cambridge St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Sandi Lam
- Baylor College of Medicine, Department of Neurosurgery, 7200 Cambridge St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Dave Fitzgerald Clarke
- Baylor College of Medicine, Department of Pediatrics, Neurology and Developmental Neuroscience Section, 6701 Fannin St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurology, Epilepsy Center, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Ya-Chen Tina Shih
- University of Texas MD Anderson Cancer Center, Department of Health Services Research, 1155 Pressler St., Houston, TX 77030, United States of America.
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Gushue C, Miller R, Sheikh S, Allen ED, Tobias JD, Hayes D, Tumin D. Gaps in health insurance coverage and emergency department use among children with asthma. J Asthma 2018; 56:1070-1078. [PMID: 30365346 DOI: 10.1080/02770903.2018.1523929] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: Gaps in health insurance coverage may complicate asthma management and increase emergency department (ED) use. Using two nationally-representative surveys, we characterize the prevalence of coverage gaps among children with asthma, and describe their association with ED visits in this population. Methods: De-identified data were obtained from the 2016 National Survey of Children's Health (NSCH) and National Health Interview Survey (NHIS). Among children with asthma, we classified coverage over the past year as: (1) continuous private, (2) continuous public, (3) gap in coverage, and (4) continuously uninsured. The primary outcome was all-cause ED visits in the past year (both surveys). Secondary outcomes included unmet health care needs (NSCH), asthma-related ED visits or hospitalizations (NHIS) and asthma exacerbations (NHIS). Results: The analysis included 3739 (NSCH) and 854 (NHIS) children with asthma, representing a population of 5.5 million children in the US. Estimated prevalence of coverage gaps was 5% in the NSCH and 3% in the NHIS. On multivariable ordinal logistic regression using NSCH data, coverage gaps were associated with increased all-cause ED use (OR = 2.5; 95% CI: 1.3, 4.7, p = 0.005), compared to continuous private coverage. Further analysis confirmed higher odds of unmet health care needs, asthma exacerbations, and asthma-related ED visits among children with coverage gaps. Conclusions: Children with asthma who experience insurance coverage gaps have increased ED use, possibly related to poorer access to appropriate health care. Protecting insurance coverage continuity may reduce ED use and improve clinical outcomes in this population.
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Affiliation(s)
- Courtney Gushue
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rebecca Miller
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Shahid Sheikh
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Elizabeth D Allen
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Don Hayes
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pulmonary and Critical Care Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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12
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Soylu TG, Elashkar E, Aloudah F, Ahmed M, Kitsantas P. Racial/ethnic differences in health insurance adequacy and consistency among children: Evidence from the 2011/12 National Survey of Children's Health. J Public Health Res 2018; 7:1280. [PMID: 29780766 PMCID: PMC5941257 DOI: 10.4081/jphr.2018.1280] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 04/14/2018] [Indexed: 11/23/2022] Open
Abstract
Background Surveillance of disparities in healthcare insurance, services and quality of care among children are critical for properly serving the medical/healthcare needs of underserved populations. The purpose of this study was to assess racial/ethnic differences in children's (0 to 17 years old) health insurance adequacy and consistency (child has insurance coverage for the last 12 months). Design and methods We used data from the 2011/2012 National Survey of Children's Health (n=79,474). Descriptive statistics and logistic regression analyses were conducted to examine the distribution and influence of several sociodemographic/family related factors on insurance adequacy and consistency across different racial/ethnic groups. Results Stratified analyses by race/ethnicity revealed that white and black children living in households at or below 299% of the Federal Poverty Level (FPL) were approximately 29 to 42% less likely to have adequate insurance compared to children living in families of higher income levels. Regardless of race/ethnicity, we found that children with public health insurance were more likely to have adequate insurance than their privately insured counterparts, while adolescents were at greater risk of inadequate coverage. Hispanic and black children were more likely to lack consistent insurance coverage. Conclusions This study provides evidence that racial/ethnic differences in adequate and consistent health insurance exists with both white and minority children being affected adversely by poverty. Establishing outreach programs for low income families, and cross-cultural education for healthcare providers may help increase health insurance adequacy and consistency within certain underserved populations.
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Affiliation(s)
- Tulay G Soylu
- Department of Health Administration and Policy, George Mason University, Fairfax VA, USA
| | - Eman Elashkar
- Department of Health Administration and Policy, George Mason University, Fairfax VA, USA
| | - Fatemah Aloudah
- Department of Health Administration and Policy, George Mason University, Fairfax VA, USA
| | - Munir Ahmed
- Department of Health Administration and Policy, George Mason University, Fairfax VA, USA
| | - Panagiota Kitsantas
- Department of Health Administration and Policy, George Mason University, Fairfax VA, USA
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13
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Diep J, Fagnano M, Tremblay P, Halterman JS. The relationship between caregivers' subjective social status and asthma symptoms and management for urban children. J Asthma 2018; 56:211-217. [PMID: 29494268 DOI: 10.1080/02770903.2018.1437176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Subjective social status (SSS) is a person's perception of his/her social standing among others. We explored the relationship between caregivers' SSS and asthma symptoms, visits, and medication use among children with persistent asthma. METHODS We analyzed baseline data of children (3-10 years) from the SB-TEAM trial in Rochester, NY. Using a modified MacArthur Scale of SSS, caregivers rated themselves "a lot worse off" to "a lot better off" compared to 4 groups (e.g., neighbors). "Low SSS" was defined by a response of "a lot worse off" or "somewhat worse off" for any of the referent groups. Caregivers reported their child's asthma symptoms, healthcare visits for asthma, and medication use. Bivariate and multivariate statistics were used. RESULTS We found that, of the 230 children enrolled (participation rate:78%, 62% Black, 72% Medicaid), 29% of caregivers had low SSS. Caregivers with low SSS had more depressive symptoms (46% vs. 28%) and lower social support (69.1 vs. 77.7). In multivariable analyses, children of caregivers with low SSS had fewer symptom-free days/2 weeks (5.8 vs. 7.9, p = .01). While they were more likely to have a routine asthma visit in the past year (35% vs. 23%, adjusted p = .03), there was no difference in their use of preventive medication. CONCLUSIONS Many caregivers of children with persistent asthma report low SSS. While children of these caregivers had fewer symptom-free days, they were not more likely to use preventive medications. Efforts are needed to support these caregivers to ensure optimal preventive care and reduce morbidity.
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Affiliation(s)
- Judy Diep
- a University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Maria Fagnano
- a University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Paul Tremblay
- a University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Jill S Halterman
- a University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
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Abstract
This study assessed children's unmet health-care needs within different family types (two-parent biological/adoptive, two-parent stepfamily, and single-mother family type) using data from the 2011/2012 National Survey of Children's Health. Findings indicate that 10.4% of children in single-mother family types had unmet health-care needs compared to 8.7% of children from a two-parent stepfamily and 5.3% for those from two-parent biological/adoptive families. Further analyses revealed racial/ethnic disparities with Black children from two parent-biological/adoptive families being 1.54 (95% confidence interval 1.13, 2.05) times more likely to have unmet health-care needs, while Hispanic children were less likely to have unmet health-care needs relative to their white counterparts. Children from lower income two-parent families had a higher likelihood of unmet health-care needs. The noncontinuous insurance coverage was a risk factor for increasing unmet health-care needs across all three different family types. These findings show major differences in unmet health-care needs among children living in different family structure types. It is recommended that interventions for increasing access to care need to be tailored differently across various family types in order to achieve continuous and sufficient health-care services for our children.
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Affiliation(s)
- Katherine Irvin
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
| | - Farhan Fahim
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
| | - Saeed Alshehri
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
| | - Panagiota Kitsantas
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
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15
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Liu X, Guo Y, Li D, Cui Z, Liu Y, Li C, Ma J. The prevalence and long-term variation of hospital readmission for patients with diabetes in Tianjin, China: A cross-sectional study. Medicine (Baltimore) 2017; 96:e7953. [PMID: 29049189 PMCID: PMC5662355 DOI: 10.1097/md.0000000000007953] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Little is known about hospital readmission for patients with diabetes in China. We aimed to assess the temporal pattern, risk factors, and variations of all-cause readmission among hospitalized patients with diabetes in Tianjin, China, from 2008 to 2013.The Tianjin Basic Medical Insurance Register System database was used to identify discharged patients with diabetes from 2008 to 2013. The influential factors and trends of rehospitalization were analyzed for 30-, 60- and 90-day predicted readmission rates. The Blinder-Oaxaca decomposition was used to explain the readmission variations between 2008 and 2013.The long stay-time at the index hospitalization is a shared risk factor for readmission at 30, 60, and 90 days each year. The 90-day predicted readmission rates were the highest for each year (all P < .001). The adjusted readmission rates generally decreased by year (all P < .001), except for at the 90-day interval, which decreased in 2010 and slightly increased in 2013 (from 7.47% in 2012 to 7.65% in 2013). If the patients had been readmitted to the hospital in 2013 and the only changes that had occurred since 2008 were observable characteristics, then the readmission rates would have decreased by 0.84%, 0.27%, and 0.18% at 30, 60, and 90 days, respectively. The potential policy changes decreased the readmission rates at 1.35%, 2.01%, and 1.04% for the 3 intervals, respectively.Identifying targeted factors for the decrease in readmission rates may help to control readmission, particularly for long-interval patients.
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16
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Janevic MR, Baptist AP, Bryant-Stephens T, Lara M, Persky V, Ramos-Valencia G, Uyeda K, Hazan R, Garrity A, Malveaux FJ. Effects of pediatric asthma care coordination in underserved communities on parent perceptions of care and asthma-management confidence. J Asthma 2016; 54:514-519. [PMID: 27901627 DOI: 10.1080/02770903.2016.1242136] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Disparities by race and socioeconomic status persist in pediatric asthma morbidity, mortality, and treatment. Improving parent/provider communication and parents' asthma-management confidence may result in better asthma control in vulnerable populations. The Merck Childhood Asthma Network, Inc. funded an initiative to implement medical-social care coordination to improve asthma outcomes at sites in four low-income, urban communities (Los Angeles, CA; Philadelphia, PA; Chicago, IL; and San Juan, PR.) As part of a cross-site evaluation of this effort, pre- post-program changes in parents' reports of asthma care and management were assessed. METHODS Across sites, 805 parents or other caregivers responded to a baseline survey that was repeated one year later following their child's participation in care coordination. Parents' asthma-management confidence, as well as their perceptions of provider access, trust, and communication, were measured with Likert scales. Linear mixed models were used to assess improvement in these variables, across and within sites, adjusting for sociodemographics. RESULTS Pooled across sites, the adjusted mean estimate for all outcomes showed a significant improvement (p <.05) from baseline to follow-up. Knowledge and Between-Provider Communication improved significantly (p <.05) within all four sites; Access improved significantly in Chicago, Philadelphia, and Puerto Rico; Trust improved significantly in Chicago, Los Angeles, and Philadelphia; and Patient-Provider Communication improved significantly in Philadelphia only. CONCLUSION Pediatric asthma care coordination, as implemented variously in diverse settings, was associated with improvement in parents' perceptions of asthma care and self-reported asthma-management knowledge and confidence. This positive impact on parents may help sustain care coordination's impact on children.
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Affiliation(s)
- Mary R Janevic
- a School of Public Health, University of Michigan , Ann Arbor , MI , USA
| | - Alan P Baptist
- b Division of Allergy and Clinical Immunology , University of Michigan Medical School , Ann Arbor , MI , USA
| | | | - Marielena Lara
- d Children's Hospital of Los Angeles, University of Southern California , Los Angeles , CA , USA.,e RAND Corporation , Santa Monica , CA , USA
| | - Victoria Persky
- f University of Illinois at Chicago School of Public Health , Chicago , IL , USA
| | | | - Kimberly Uyeda
- h Los Angeles Unified School District , Los Angeles , CA , USA
| | - Rebecca Hazan
- a School of Public Health, University of Michigan , Ann Arbor , MI , USA
| | - Ashley Garrity
- a School of Public Health, University of Michigan , Ann Arbor , MI , USA
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17
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Heintzman J, Bailey SR, DeVoe J, Cowburn S, Kapka T, Duong TV, Marino M. In Low-Income Latino Patients, Post-Affordable Care Act Insurance Disparities May Be Reduced Even More than Broader National Estimates: Evidence from Oregon. J Racial Ethn Health Disparities 2016; 4:329-336. [PMID: 27105630 DOI: 10.1007/s40615-016-0232-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 03/29/2016] [Accepted: 03/31/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Early survey evidence suggests a reduction of disparities in insurance coverage between Latinos and non-Hispanic Whites post-Affordable Care Act (ACA). These findings may not describe the insurance status of vulnerable, low-income Latino populations served in community health centers (CHCs) over the course of this policy change. Cross-sectional surveys also may be of limited use in describing longitudinal phenomena such as changes in health insurance status. METHODS Using electronic health record (EHR) data, we compared the insurance status of N = 42,392 low-income patients served in 23 CHCs in Oregon, by race/ethnicity and language, over a period of 6 years straddling the implementation of ACA-related Medicaid expansion on January 1, 2014. FINDINGS Prior to 2014, Spanish-preferring Latinos were more likely to be uninsured than English-preferring Latinos and non-Hispanic Whites. Among uninsured patients who returned for at least one visit in 2014, Spanish-preferring Latinos had the largest increase in insurance coverage rates, and all three racial/ethnic/language groups had similar rates of insurance coverage. There were no racial/ethnic/language differences between those who did and did not have visit in 2014. CONCLUSION Among previously uninsured low-income patients returning to Oregon CHCs, insurance disparities were eliminated after Medicaid expansion, especially in Spanish-speaking Latinos. Further study is needed to understand the elimination of insurance disparities in this cohort.
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Affiliation(s)
- John Heintzman
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Drive, Mail Code FM, Portland, OR, 97239, USA.
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Drive, Mail Code FM, Portland, OR, 97239, USA
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Drive, Mail Code FM, Portland, OR, 97239, USA.,OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, USA
| | - Stuart Cowburn
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, USA
| | - Tanya Kapka
- Virginia Garcia Memorial Health Center, 2935 SW Cedar Hills Blvd, Beaverton, OR, 97005, USA
| | - Truc-Vi Duong
- Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Drive, Mail Code FM, Portland, OR, 97239, USA.,Division of Biostatistics, Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Drive, Mail Code FM, Portland, OR, 97239, USA
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18
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Smits-Seemann RR, Kaul S, Hersh AO, Fluchel MN, Boucher KM, Kirchhoff AC, Smits-Seemann RR, Kaul S, Hersh AO, Fluchel MN, Boucher KM, Kirchhoff AC. ReCAP: Gaps in Insurance Coverage for Pediatric Patients With Acute Lymphoblastic Leukemia. J Oncol Pract 2016; 12:175-6; e207-14. [DOI: 10.1200/jop.2015.005686] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
QUESTION ASKED: We sought to determine the likelihood that pediatric and adolescent acute lymphoblastic leukemia (ALL) patients experience a gap in health insurance coverage in the first 2 years of therapy. SUMMARY ANSWER: We found that 12% of patients with ALL in our sample who had insurance at diagnosis experienced a gap in insurance coverage during the first 2 years of therapy; that is, they had one or more clinic encounter at which they did not have insurance. Patients with public insurance at diagnosis were more likely to experience an insurance gap than those with private insurance at diagnosis, and those diagnosed in more recent years were less likely to experience a gap. METHODS/APPROACH: We determined insurance status at all clinic encounters at a tertiary children’s hospital within 2 years of diagnosis for patients diagnosed with ALL between 1998 and 2010, and calculated the odds of a gap occurring on the basis of demographic and diagnostic variables. BIAS, CONFOUNDING FACTOR(S), DRAWBACKS: Our assessment is from years before the roll-out of key Patient Protection and Affordable Care Act provisions, which should improve insurance coverage for pediatric and adolescent patients with ALL. In addition, we lacked information on patient or caregiver socioeconomic status, which may be important for explaining insurance gaps. Finally, our assessment is based on a single institution. REAL-LIFE IMPLICATIONS: Gaps in health insurance may exacerbate the financial and emotional burden associated with pediatric and adolescent cancer. Understanding the likelihood that these gaps will occur, as well as predictors of insurance gaps, will allow social workers and other providers to help families manage anticipated changes in insurance, with the goal of reducing unnecessary burden. [Figure: see text]
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Affiliation(s)
- Rochelle R. Smits-Seemann
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Sapna Kaul
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Aimee O. Hersh
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Mark N. Fluchel
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Kenneth M. Boucher
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Anne C. Kirchhoff
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Rochelle R. Smits-Seemann
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Sapna Kaul
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Aimee O. Hersh
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Mark N. Fluchel
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Kenneth M. Boucher
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Anne C. Kirchhoff
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
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19
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Relationship of Affordable Care Act Implementation to Emergency Department Utilization Among Young Adults. Ann Emerg Med 2016; 67:714-720.e1. [PMID: 26778281 DOI: 10.1016/j.annemergmed.2015.11.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/18/2015] [Accepted: 11/23/2015] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE The 2010 provision of the Patient Protection and Affordable Care Act (ACA) extended eligibility for health insurance for young adults aged 19 to 25 years. It is unclear, however, how expanded coverage changes health care behavior and promotes efficient use of emergency department (ED) services. Our objective was to use population-level emergency department data to characterize any changes in diagnoses seen in ED among young adults since the implementation of the ACA dependent coverage expansion. METHODS We performed a difference-in-differences analysis of 2009 to 2011 ED visits from California, Florida, and New York, using all-capture administrative data to determine how the use of ED services changed for clinical categories after the ACA provision among young adults aged 19 to 25 years compared with slightly older adults unaffected by the provision, aged 26 to 31 years. RESULTS We analyzed a total of 10,158,254 ED visits made by 4,734,409 patients. After the implementation of the 2010 ACA provision, young adults had a relative decrease of 0.5% ED visits per 1,000 people compared with the older group. For the majority of diagnostic categories, young adults' rates and risk of visit did not change relative to that of slightly older adults after the implementation of the ACA. However, although young adults' ED visits significantly increased for mental illnesses (2.6%) and diseases of the circulatory system (eg, nonspecific chest pain) (4.8%), visits decreased for pregnancy-related diagnoses and diseases of the skin (eg, cellulitis, abscess) compared with that of the older group (3.7% and 3.1%, respectively). CONCLUSION Our results indicate that increased coverage has kept young adults out of the ED for specific conditions that can be cared for through access to other channels. As EDs face capacity challenges, these results are encouraging and offer insight into what could be expected under further insurance expansions from health care reform.
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20
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Rangachari P, Mehta R, Rethemeyer RK, Ferrang C, Dennis C, Redd V. Short or Long End of the Lever? Associations between Provider Communication of the "Asthma-Action Plan" and Outpatient Revisits for Pediatric Asthma. JOURNAL OF HOSPITAL ADMINISTRATION 2015; 4:26-39. [PMID: 29201264 PMCID: PMC5706774 DOI: 10.5430/jha.v4n5p26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND At the Children's Hospital of Georgia (CHOG), we found that outpatient revisits for pediatric asthma were significantly above national norms. According to the NIH, costly hospital revisits for asthma can be prevented through guidelines-based self-management of asthma, central to which, is the use of a written Asthma-Action Plan (AAP). PURPOSE The asthma services literature has emphasized the role of the healthcare provider in promoting asthma self-management using the AAP, to prevent hospital revisits. On the other hand, the asthma policy literature has emphasized the need for community-based interventions to promote asthma self-management. A gap remains in understanding the extent of leverage that healthcare providers may have in preventing hospital revisits for asthma, through effective communication of AAP in the outpatient setting. Our study sought to address this gap. METHODS We conducted a 6-month intervention to implement "patient-and-family-centered communication of the AAP" in CHOG outpatient clinics, based on the "change-management" theoretical framework. Provider communication of AAP was assessed through a survey of "Parent Understanding of the Child's AAP." A quasi-experimental approach was used to measure outpatient revisits for pediatric asthma, pre- and post-intervention. RESULTS Survey results showed that provider communication of the AAP was unanimously perceived highly positively by parents of pediatric asthma patients, across various metrics of patient-centered care. However, there were no statistically significant differences in outpatient "revisit behavior" for pediatric asthma between pre- and post-intervention periods after controlling for several demographic variables. Additionally, revisits remained significantly above national norms. CONCLUSIONS Results suggest limited potential of "effective provider communication of AAP," in reducing outpatient revisits for pediatric asthma; and indicate need for broader community-based interventions to address patient life variables impacting self-management and hospital revisits for pediatric asthma. Findings suggest need for a revised "socio-ecological" theoretical framework, and also provide insight into various policy, research, and practice implications for asthma management and control.
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Affiliation(s)
- Pavani Rangachari
- Department of Health Management & Informatics, Georgia Regents University, Augusta, Georgia, United States
| | - Renuka Mehta
- Department of Pediatrics, Georgia Regents University, Augusta, Georgia, United States
| | - R Karl Rethemeyer
- Department of Public Administration & Policy, University at Albany, State University of New York, United States
| | - Carole Ferrang
- Children's Hospital of Georgia, Georgia Regents Medical Center, Augusta, Georgia, United States
| | - Clifton Dennis
- CSRA Asthma Coalition, Georgia Regents University, Augusta, Georgia, United States
| | - Vickie Redd
- Children's Hospital of Georgia, Georgia Regents Medical Center, Augusta, Georgia, United States
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21
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Ferreira-Magalhães M, Pereira AM, Sa-Sousa A, Morais-Almeida M, Azevedo I, Azevedo LF, Fonseca JA. Asthma control in children is associated with nasal symptoms, obesity, and health insurance: a nationwide survey. Pediatr Allergy Immunol 2015; 26:466-73. [PMID: 25939454 DOI: 10.1111/pai.12395] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND This study aimed to estimate the prevalence of asthma control and determinants of poor control in the Portuguese pediatric population (<18 years); secondarily, we described asthma-related healthcare services and medication use. METHODS Data of 98 children with current asthma, from the second phase of a nationwide population-based telephone survey (INAsma study), were analyzed. Asthma control definition was based on GINA criteria, grouping partially controlled and uncontrolled asthma as 'not-controlled asthma' (NCA). We used multivariate logistic regression to study factors associated with NCA and with unscheduled medical visits for asthma. RESULTS About half of the children had NCA (49%, 95% CI 39-59%). In the multivariate model, risk factors for NCA were as follows: substantial nasal symptoms (a OR 6.80), overweight/obesity (a OR 3.44), and not having health insurance (a OR 3.78). All the children with NCA had nasal symptoms, and the lack of asthma control was also associated with the increasing number of nasal symptoms (p < 0.001). In the previous year, 90% (95% CI 84-96%) of children with current asthma had healthcare visits and 67% (95% CI 58-77%) used medication for asthma. The risk of unscheduled medical visits was higher in children with nasal symptoms (a OR 3.63) and in those without health insurance (a OR 2.79), and lower in adolescents (a OR 0.19). CONCLUSIONS Half of the children with asthma were poorly controlled. Nasal symptoms and obesity are important determinants of asthma control. Children without health insurance are at greater risk of poor asthma outcomes; this association is reported for the first time in a European country.
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Affiliation(s)
- Manuel Ferreira-Magalhães
- Department of Pediatrics, Centro Hospitalar de S. João, Porto, Portugal.,CINTESIS - Center for Research in Health Technologies and Information Systems - Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Pediatrics - Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana Margarida Pereira
- CINTESIS - Center for Research in Health Technologies and Information Systems - Faculty of Medicine, University of Porto, Porto, Portugal.,Allergy Unit, CUF Institute & Hospital, Porto, Portugal
| | - Ana Sa-Sousa
- CINTESIS - Center for Research in Health Technologies and Information Systems - Faculty of Medicine, University of Porto, Porto, Portugal
| | - Mário Morais-Almeida
- Allergy and Clinical Immunology Division Unit, CUF Descobertas and CUF Infante Santo Hospital, Lisbon, Portugal.,Sociedade Portuguesa de Alergologia e Imunologia Clínica, Lisbon, Portugal
| | - Inês Azevedo
- Department of Pediatrics, Centro Hospitalar de S. João, Porto, Portugal.,Department of Pediatrics - Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luís Filipe Azevedo
- CINTESIS - Center for Research in Health Technologies and Information Systems - Faculty of Medicine, University of Porto, Porto, Portugal.,Health Information and Decision Sciences Department - Faculty of Medicine, Porto University, Porto, Portugal
| | - João Almeida Fonseca
- CINTESIS - Center for Research in Health Technologies and Information Systems - Faculty of Medicine, University of Porto, Porto, Portugal.,Allergy Unit, CUF Institute & Hospital, Porto, Portugal.,Health Information and Decision Sciences Department - Faculty of Medicine, Porto University, Porto, Portugal
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22
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Freund KM, Isabelle AP, Hanchate AD, Kalish RL, Kapoor A, Bak S, Mishuris RG, Shroff SM, Battaglia TA. The impact of health insurance reform on insurance instability. J Health Care Poor Underserved 2015; 25:95-108. [PMID: 24583490 DOI: 10.1353/hpu.2014.0061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We investigated the impact of the 2006 Massachusetts health care reform on insurance coverage and stability among minority and underserved women. We examined 36 months of insurance claims among 1,946 women who had abnormal cancer screening at six community health centers pre-(2004-2005) and post-(2007-2008) insurance reform. We examined frequency of switches in insurance coverage as measures of longitudinal insurance instability. On the date of their abnormal cancer screening test, 36% of subjects were publicly insured and 31% were uninsured. Post-reform, the percent ever uninsured declined from 39% to 29% (p .001) and those consistently uninsured declined from 23% to 16%. To assess if insurance instability changed between the pre- and post-reform periods, we conducted Poisson regression models, adjusted for patient demographics and length of time in care. These revealed no significant differences from the pre- to post-reform period in annual rates of insurance switches, incident rate ratio 0.98 (95%- CI 0.88-1.09). Our analysis is limited by changes in the populations in the pre- and post-reform period and inability to capture care outside of the health system network. Insurance reform increased stability as measured by decreasing uninsured rates without increasing insurance switches.
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Pennarola BW, Rodday AM, Bingen K, Schwartz LA, Patel SK, Syrjala KL, Mayer DK, Ratichek SJ, Guinan EC, Kupst MJ, Hibbard JH, Parsons SK. Changing factors associated with parent activation after pediatric hematopoietic stem cell transplant. Support Care Cancer 2014; 23:1997-2006. [PMID: 25519755 DOI: 10.1007/s00520-014-2544-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/30/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE To identify factors associated with parent activation in parents of children undergoing pediatric hematopoietic stem cell transplant (HSCT) in the 6 months following HSCT, and to address if their association with parent activation changes over time. METHODS Measures for this analysis, including the Parent-Patient Activation Measure (Parent-PAM), were completed by parents (N = 198) prior to their child's HSCT preparative regimen and again at 6 months post-HSCT. Clinical data were also collected. A repeated measures model was built to estimate the association between clinical and demographic factors and parent well-being on Parent-PAM scores. Interactions with time were considered to test for changing effects over time. RESULTS Throughout the HSCT course, older parent age was associated with lower Parent-PAM scores (β = -0.29, p = 0.02) and never being married was associated with higher scores (versus married, β = 12.27, p = 0.03). While higher parent emotional functioning scores were not associated with activation at baseline, they were important at 6 months (baseline, β = -0.002, p = 0.96; interaction, β = 0.14, p = 0.03). At baseline, longer duration of illness was associated with increased activation, but this effect diminished with time (baseline, β = 3.29, p = 0.0002; interaction, β = -2.40, p = 0.02). Activation levels dropped for parents of children who went from private to public insurance (baseline, β = 2.95, p = 0.53; interaction, β = -13.82, p = 0.004). Clinical events did not affect Parent-PAM scores. CONCLUSIONS Our findings reveal important changes in the factors associated with parent activation in the first 6 months after pediatric HSCT. These findings may reflect the emotional and financial toll of pediatric HSCT on parent activation.
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Affiliation(s)
- Brian W Pennarola
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA,
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Heintzman J, Marino M, Hoopes M, Bailey S, Gold R, Crawford C, Cowburn S, O'Malley J, Nelson C, DeVoe JE. Using electronic health record data to evaluate preventive service utilization among uninsured safety net patients. Prev Med 2014; 67:306-10. [PMID: 25124279 PMCID: PMC4363138 DOI: 10.1016/j.ypmed.2014.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/28/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study compared the preventive service utilization of uninsured patients receiving care at Oregon community health centers (CHCs) in 2008 through 2011 with that of continuously insured patients at the same CHCs in the same period, using electronic health record (EHR) data. METHODS We performed a retrospective cohort analysis, using logistic mixed effects regression modeling to calculate odds ratios and rates of preventive service utilization for patients without insurance, or with continuous insurance. RESULTS CHCs provided many preventive services to uninsured patients. Uninsured patients were less likely than continuously insured patients to receive 5 of 11 preventive services, ranging from OR 0.52 (95% CI: 0.35-0.77) for mammogram orders to 0.75 (95% CI: 0.66-0.86) for lipid panels. This disparity persisted even in patients who visited the clinic regularly. CONCLUSION Lack of insurance is a barrier to preventive service utilization, even in patients who can access care at a CHC. Policymakers in the United States should continue to address this significant prevention disparity.
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Affiliation(s)
- John Heintzman
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., FM, Portland, OR 97239, United States.
| | - Miguel Marino
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., FM, Portland, OR 97239, United States.
| | - Megan Hoopes
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR 97201, United States.
| | - Steffani Bailey
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., FM, Portland, OR 97239, United States.
| | - Rachel Gold
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1098, United States.
| | - Courtney Crawford
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., FM, Portland, OR 97239, United States.
| | - Stuart Cowburn
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR 97201, United States.
| | - Jean O'Malley
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., FM, Portland, OR 97239, United States.
| | - Christine Nelson
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR 97201, United States.
| | - Jennifer E DeVoe
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., FM, Portland, OR 97239, United States.
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Guevara JP, Moon J, Hines EM, Fremont E, Wong A, Forrest CB, Silber JH, Pati S. Continuity of Public Insurance Coverage. Med Care Res Rev 2013; 71:115-37. [DOI: 10.1177/1077558713504245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.
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Affiliation(s)
| | - Jeanhee Moon
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Ettya Fremont
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Angie Wong
- Stony Brook Long Island Children’s Hospital, Stony Brook, NY, USA
| | | | | | - Susmita Pati
- Stony Brook Long Island Children’s Hospital, Stony Brook, NY, USA
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Ogbuanu C, Goodman DA, Kahn K, Long C, Noggle B, Bagchi S, Barradas D, Castrucci B. Timely access to quality health care among Georgia children ages 4 to 17 years. Matern Child Health J 2012; 16 Suppl 2:307-19. [PMID: 23054451 PMCID: PMC4538931 DOI: 10.1007/s10995-012-1146-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We examined factors associated with children's access to quality health care, a major concern in Georgia, identified through the 2010 Title V Needs Assessment. Data from the 2007 National Survey of Children's Health were merged with the 2008 Area Resource File and Health Resources and Services Administration medically underserved area variable, and restricted to Georgia children ages 4-17 years (N = 1,397). The study outcome, access to quality health care was derived from access to care (timely utilization of preventive medical care in the previous 12 months) and quality of care (compassionate/culturally effective/family-centered care). Andersen's behavioral model of health services utilization guided independent variable selection. Analyses included Chi-square tests and multinomial logit regressions. In our study population, 32.8 % reported access to higher quality care, 24.8 % reported access to moderate quality care, 22.8 % reported access to lower quality care, and 19.6 % reported having no access. Factors positively associated with having access to higher/moderate versus lower quality care include having a usual source of care (USC) (adjusted odds ratio, AOR:3.27; 95 % confidence interval, 95 % CI 1.15-9.26), and special health care needs (AOR:2.68; 95 % CI 1.42-5.05). Lower odds of access to higher/moderate versus lower quality care were observed for non-Hispanic Black (AOR:0.31; 95 % CI 0.18-0.53) and Hispanic (AOR:0.20; 95 % CI 0.08-0.50) children compared with non-Hispanic White children and for children with all other forms of insurance coverage compared with children with continuous-adequate-private insurance. Ensuring that children have continuous, adequate insurance coverage and a USC may positively affect their access to quality health care in Georgia.
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Affiliation(s)
- Chinelo Ogbuanu
- Maternal and Child Health Epidemiology Section, Maternal and Child Health Program, Division of Public Health, Georgia Department of Community Health, 2 Peachtree Street NW, Atlanta, GA 30303, USA.
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Cordner A. The health care access and utilization of homeschooled children in the United States. Soc Sci Med 2012; 75:269-73. [DOI: 10.1016/j.socscimed.2012.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 01/22/2012] [Accepted: 02/07/2012] [Indexed: 11/16/2022]
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Fairbrother GL, Carle AC, Cassedy A, Newacheck PW. The impact of parental job loss on children's health insurance coverage. Health Aff (Millwood) 2012; 29:1343-9. [PMID: 20606186 DOI: 10.1377/hlthaff.2009.0137] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Children with private health insurance are more than six and a half times as likely to lose coverage in the three months after one or both of their parents loses a job, compared to children whose parents remain employed. In the current economic environment, this finding is especially troubling. We estimate that for every 1,000 jobs lost, 311 privately insured children lose coverage and more than 45 percent of the poorest and most vulnerable of privately insured children became uninsured. Much more effort is needed to quickly enroll children in public health insurance programs when their parents suffer a job loss.
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Ogbuanu C, Goodman D, Kahn K, Noggle B, Long C, Bagchi S, Barradas D, Castrucci B. Factors Associated with Parent Report of Access to Care and the Quality of Care Received by Children 4 to 17 Years of Age in Georgia. Matern Child Health J 2012; 16 Suppl 1:S129-42. [DOI: 10.1007/s10995-012-1002-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Perry TT, Rettiganti M, Brown RH, Nick TG, Jones SM. Uncontrolled asthma and factors related to morbidity in an impoverished, rural environment. Ann Allergy Asthma Immunol 2012; 108:254-9. [PMID: 22469445 DOI: 10.1016/j.anai.2012.01.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 01/23/2012] [Accepted: 01/24/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Asthma disproportionately affects children living in impoverished communities; however, factors related to asthma morbidity among impoverished rural children have not been adequately described. OBJECTIVE To examine factors associated with asthma morbidity among rural children living in the Arkansas Delta region. METHODS We performed a cross-sectional investigation of 109 rural children with asthma enrolled in public schools in the Arkansas Delta region. A questionnaire format and home inspection were used to examine participant, caregiver, and home characteristics. RESULTS The median age of the study participants was 9 years, 83% were African American, and 71% had an annual household income of $20,000 or less. Ninety-eight percent of participants were insured, and most fit the criteria for uncontrolled asthma, yet only 23% reported taking inhaled corticosteroids. Transportation problems were cited by 20%. In the past 4 weeks, more than 50% reported rescue medication use or exercise limitations of 2 or more days per week or nocturnal symptoms of more than 2 nights per month. Emergency department visits in the past 6 months were reported by 28%, and 43% reported an unscheduled physician's visits for asthma in the past 3 months. Sixty-four percent had 1 or more positive allergen skin test results, and allergic sensitization was associated with exposure to dust mite, dog, mouse, and cockroach allergens in the home. CONCLUSION Asthma morbidity was high among this cohort of atopic asthmatic children in the Arkansas Delta. Overuse of rescue medications and underuse of inhaled corticosteroids were prevalent even though the population was highly insured and had frequent health care use. Future asthma health initiatives should focus on the unique challenges associated with translating national guidelines-based care to rural pediatric populations. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00590304.
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Affiliation(s)
- Tamara T Perry
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72202, USA.
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Kit BK, Simon AE, Ogden CL, Akinbami LJ. Trends in preventive asthma medication use among children and adolescents, 1988-2008. Pediatrics 2012; 129:62-9. [PMID: 22144697 DOI: 10.1542/peds.2011-1513] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine trends in preventive asthma medication (PAM) use among children with current asthma in the United States from 1988 to 2008. METHODS We performed a cross-sectional analysis of PAM use among 2499 children aged 1 to 19 years with current asthma using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) during 3 time periods: 1988-1994, 1999-2002, and 2005-2008. PAMs included inhaled corticosteroids, leukotriene receptor antagonists, long-acting β-agonists, mast-cell stabilizers, and methylxanthines. RESULTS Among children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988-1994 to 34.9% (SE: 3.3) in 2005-2008 (P < .001 for trend). Adjusting for age, gender, race/ethnicity, and health insurance status, the odds of PAM use were higher in 2005-2008 compared with 1988-1994 (adjusted odds ratio [aOR] = 2.6; 95% confidence interval [CI]: 1.5-4.5). A multivariate analysis, combining all 3 time periods, showed lower use of PAMs among non-Hispanic black (aOR = 0.5 [95% CI: 0.4-0.7]) and Mexican American (aOR = 0.6 [95% CI: 0.4-0.9]) children compared to non-Hispanic white children. PAM use was also lower in 12 to 19 year olds compared with 1 to 5 year olds and also in children who did not have health insurance compared with those who did. CONCLUSIONS Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American children, adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM.
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Affiliation(s)
- Brian K Kit
- Division of Health and Nutrition Examination Surveys, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA.
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Palli SR, Mehta S, Aparasu RR. Prevalence and predictors of human papillomavirus vaccination in adolescent girls. J Am Pharm Assoc (2003) 2012; 52:52-8. [DOI: 10.1331/japha.2012.10195] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
OBJECTIVES To outline the prevalence and disparities of asthma among school-aged urban minority youth, causal pathways through which poorly controlled asthma adversely affects academic achievement, and proven or promising approaches for schools to address these problems. METHODS Literature review. RESULTS Asthma is the most common chronic disease affecting youth in the United States; almost 10 million youth under 18 (14%) have received a diagnosis and 6.8 million (9%) have active asthma. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs. 8.8%), as were average annual estimates of asthma attacks (8.4% vs. 5.8%). Urban minority youth have highly elevated prevalence of poorly controlled asthma as evidenced by overuse of emergency departments and under-use of efficacious medications. Poorly controlled asthma has functional consequences on cognition, connectedness with school, and absenteeism. Exemplary asthma programs include management and support systems, school health and mental health services, asthma education, healthy school environments, physical education and activity, and coordination of school, family, and community efforts. CONCLUSIONS Asthma and, more importantly, poorly controlled asthma are highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement through its effects on cognition, school connectedness, and absenteeism, and effective practices are available for schools to address this problem. To reduce the adverse effects of poorly controlled asthma on learning, a multifaceted approach to asthma control and prevention in which schools can and must play a central role is essential.
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Affiliation(s)
- Charles E Basch
- Department of Health and Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027, USA.
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Wu BH, Cabana MD, Hilton JF, Ly NP. Race and asthma control in the pediatric population of Hawaii. Pediatr Pulmonol 2011; 46:442-51. [PMID: 21194172 DOI: 10.1002/ppul.21387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 08/09/2010] [Accepted: 09/21/2010] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The racially unique population of Hawaii has one of the highest prevalences of childhood asthma in America. We estimate the prevalence of impaired asthma control among asthmatic children in Hawaii and determine which factors are associated with impaired control. PATIENTS AND METHODS We analyzed data from 477 asthmatic children living in Hawaii participating in the 2006-2008 Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-Back Surveys. Impaired asthma control was modeled after 2007 National Asthma Education and Prevention Program guidelines. Univariate and multivariate analyses were used to identify factors associated with impaired asthma control. RESULTS Children (53.8%) with asthma were either part or full Native Hawaiian/Pacific Islander. While 35.6% of asthmatic children met criteria for impaired asthma control, being part or full Native Hawaiian/Pacific Islander was not associated with impaired control. Only 31.1% of children with impaired control reported the use of inhaled corticosteroids despite >80% having had a routine checkup for asthma in the past year and receipt of asthma education from a healthcare provider. CONCLUSION A large proportion of asthmatic children in Hawaii have impaired asthma control that does not appear to be associated with race but may be associated with inadequate pharmacologic therapy. While a significant percentage reported receiving routine asthma care and asthma education, a minority reported using inhaled corticosteroids. Reasons for this discrepancy between asthma assessment and treatment are unclear. However, additional education on part of the physician, community, and healthcare system are likely to improve management and reduce morbidity in this population.
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Affiliation(s)
- Brian H Wu
- Division of Pediatric Pulmonary Medicine, Department of Pediatrics, University of California San Francisco, California.
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Bethell CD, Kogan MD, Strickland BB, Schor EL, Robertson J, Newacheck PW. A national and state profile of leading health problems and health care quality for US children: key insurance disparities and across-state variations. Acad Pediatr 2011; 11:S22-33. [PMID: 21570014 DOI: 10.1016/j.acap.2010.08.011] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 08/19/2010] [Accepted: 08/27/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Parent/consumer-reported data is valuable and necessary for population-based assessment of many key child health and health care quality measures relevant to both the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 and the Patient Protection and Affordable Care Act of 2010 (ACA). OBJECTIVES The aim of this study was to evaluate national and state prevalence of health problems and special health care needs in US children; to estimate health care quality related to adequacy and consistency of insurance coverage, access to specialist, mental health and preventive medical and dental care, developmental screening, and whether children meet criteria for having a medical home, including care coordination and family centeredness; and to assess differences in health and health care quality for children by insurance type, special health care needs status, race/ethnicity, and/or state of residence. METHODS National and state level estimates were derived from the 2007 National Survey of Children's Health (N = 91,642; children aged 0-17 years). Variations between children with public versus private sector health insurance, special health care needs, specific conditions, race/ethnicity, and across states were evaluated using multivariate logistic regression and/or standardized statistical tests. RESULTS An estimated 43% of US children (32 million) currently have at least 1 of 20 chronic health conditions assessed, increasing to 54.1% when overweight, obesity, or being at risk for developmental delays are included; 19.2% (14.2 million) have conditions resulting in a special health care need, a 1.6 point increase since 2003. Compared with privately insured children, the prevalence, complexity, and severity of health problems were systematically greater for the 29.1% of all children who are publicly insured children after adjusting for variations in demographic and socioeconomic factors. Forty-five percent of all children in the United States scored positively on a minimal quality composite measure: 1) adequate insurance, 2) preventive care visit, and 3) medical home. A 22.2 point difference existed across states and there were wide variations by health condition (autism, 22.8, to asthma, 39.4). After adjustment for demographic and health status differences, quality of care varied between children with public versus private health insurance on all but the following 3 measures: not receiving needed mental health services, care coordination, and performance on the minimal quality composite. A 4.60 fold (gaps in insurance) to 1.27 fold (preventive dental and medical care visits) difference in quality scores was observed across states. Notable disparities were observed among publicly insured children according to race/ethnicity and across all children by special needs status and household income. CONCLUSIONS Findings emphasize the importance of health care insurance duration and adequacy, health care access, chronic condition management, and other quality of care goals reflected in the 2009 CHIPRA legislation and the ACA. Despite disparities, similarities for public and privately insured children speak to the pervasive nature of availability, coverage, and access issues for mental health services in the United States, as well as the system-wide problem of care coordination and accessing specialist care for all children. Variations across states in key areas amenable to state policy and program management support cross-state learning and improvement efforts.
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Affiliation(s)
- Christina D Bethell
- Department of Pediatrics, School of Medicine, Oregon Health & Science University, 707 SW Gaines Street, Mailcode CDRCP, Portland, Oregon 97239, USA.
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Scott L, Morphew T, Bollinger ME, Samuelson S, Galant S, Clement L, O'Cull K, Jones F, Jones CA. Achieving and maintaining asthma control in inner-city children. J Allergy Clin Immunol 2011; 128:56-63. [PMID: 21531451 DOI: 10.1016/j.jaci.2011.03.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 03/17/2011] [Accepted: 03/18/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite guidelines-defined care, inner-city children of low socioeconomic status have poor asthma control. OBJECTIVE This study evaluated time to achieve control, maintenance of control, and factors associated with well controlled asthma for pediatric patients receiving specialty-based asthma care in mobile asthma clinics designed to reduce barriers to delivering effective asthma care (the Breathmobile Program). METHODS Existing clinical data collected from January 1998 to June 2008 for 7822 pediatric patients with asthma (34,339 visits) enrolled in similarly structured mobile asthma programs across the United States evaluated the effect of asthma control on the reduction of asthma-related morbidity, time to achieve asthma control, maintenance of asthma control, and factors associated with well controlled asthma. RESULTS Comparison of pre and post year data for subjects enrolled in the program for at least 1 year revealed reductions in the percentage of patients reporting emergency department visits (mean, 66%), hospitalizations (mean, 84%), and missed school days ≥5/year (mean, 78%). Well controlled asthma was achieved by visit 3 for an estimated 80% of patients. Factors contributing to well controlled asthma include non-African American race, visit interval <90 days, and adherence to prescribed therapy. CONCLUSION This study demonstrates the ability to achieve and maintain asthma control in high-risk populations in association with intensive, accessible, guidelines-defined care with close follow-up.
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Affiliation(s)
- Lyne Scott
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA.
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Kogan MD, Newacheck PW, Blumberg SJ, Ghandour RM, Singh GK, Strickland BB, van Dyck PC. Underinsurance among children in the United States. N Engl J Med 2010; 363:841-51. [PMID: 20818845 DOI: 10.1056/nejmsa0909994] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent interest in policy regarding children's health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children's needs. METHODS We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children's Health (sample size, 91,642 children) regarding parents' or guardians' judgments of whether their children's insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home. RESULTS We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage--14.1 million children--were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality. CONCLUSIONS The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)
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Affiliation(s)
- Michael D Kogan
- Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD 20857, USA.
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Mehta S, Nagar S, Aparasu R. Unmet prescription medication need in U.S. children. J Am Pharm Assoc (2003) 2010; 49:769-76. [PMID: 19926557 DOI: 10.1331/japha.2009.08170] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To examine the nature and extent of unmet prescription medication need (UPMN) in children and its predictors using the 2003 National Survey of Children's Health (NSCH). DESIGN Retrospective cross-sectional survey. SETTING United States in 2003-2004. PARTICIPANTS Parents or guardians who knew most about child's (<18 years of age) health and health care and reported about their children's prescription medication use. INTERVENTION NSCH-a population-based telephone survey-based on complex probability sampling design. MAIN OUTCOME MEASURES Nature and extent of UPMN in children and predictors of UPMN for any reason and as a result of cost, health plan problems, and lack of insurance within the conceptual framework of the Andersen behavioral model. RESULTS According to NSCH, 0.54 million (95% CI 0.46-0.62) or 1.23% (1.05-1.41%) of children experienced UPMN. The highest prevalence of UPMN was seen among blacks (2.3%), families with income less than 200% of federal poverty level (2.4%), and those having good, fair, or poor perceived health status (3.2%). A high prevalence of UPMN was also found in children with gained (5.3%), lost (3.7%), or no insurance (6.4%). Among children with UPMN, 35.39% (28.56-42.23%) did not receive medications because of cost, 26.51% (20.28-32.74%) because of health plan problems, and 40.73% (33.21-48.24%) because of lack of insurance. Multivariate logistic regression analysis revealed that predisposing (race), enabling (poverty and insurance), and need (perceived health status and depression) factors were significantly associated with UPMN for any reason. Factors significantly associated with UPMN due to cost included enabling (insurance) and need (attention deficit hyperactivity disorder and asthma) factors. The predictors of UPMN resulting from health plan problems included predisposing (race) and enabling (insurance) factors, whereas UPMN caused by lack of insurance was only associated with an enabling factor (age). CONCLUSION More than 0.5 million children in the United States experienced UPMN, mainly as a result of cost, health plan problems, or lack of insurance. The study findings suggest that a need exists for addressing racial disparities and continuity of coverage issues in children to improve access to needed prescription medications.
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Affiliation(s)
- Sandhya Mehta
- Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Texas Medical Center, Houston, TX, USA
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Association between insurance gaps and continued antihypertension medication usage in a US national representative population. Am J Hypertens 2009; 22:1276-80. [PMID: 19779465 DOI: 10.1038/ajh.2009.188] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Medication persistence is important for adequate control of blood pressure. In this article, we assess the association between gaps in insurance coverage and continued antihypertensive medication using a US national representative sample. METHODS We used three recent panels from the Medical Expenditure Panel Survey (MEPS). Our sample included hypertensive individuals 18-65 years of age. We identified four insurance categories: (i) continuous coverage by private insurance, (ii) continuous coverage by public insurance, (iii) single or multiple gaps in coverage, and (iv) continuously uninsured. Binary logit models were used to analyze the association between interruptions in medication and insurance after controlling for socioeconomic factors. Patients with continuous private insurance were used as the reference group. Results were weighted to adjust for oversampling and clustering in the survey. RESULTS There was no statistically significant difference in the probability of medication persistence between individuals with continuous private insurance (the reference group) and individuals with continuous public insurance (adjusted odds ratio (AOR) 1.324, 95% confidence interval (CI) 0.774-2.266, P = 0.304). Compared to the reference group, individuals with insurance gaps had lower odds of continuing their medication (AOR 0.636, 95% CI 0.418-0.0.969, P = 0.035). Continuously uninsured individuals had even lower odds of medication persistence (AOR 0.462, 95% CI 0.282-0.757, P = 0.002). Age, marital status, body mass index (BMI) change, and years of education were also associated with continued medication usage. CONCLUSION Studies focusing on current insurance status may underestimate the impact of health insurance gaps and the population at risk. Continuous insurance coverage is needed to increase continued antihypertensive medication usage.
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Changes in the health burden of a national sample of children with asthma. Soc Sci Med 2009; 70:321-8. [PMID: 19850391 DOI: 10.1016/j.socscimed.2009.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Indexed: 11/20/2022]
Abstract
This paper focused on the extent to which factors that are modifiable by health policies or provider recommendations influenced the level and changes in the burden of childhood asthma. Demographic factors, access to health care services, and asthma control activities were posited to potentially influence the level and changes in health burden of children with asthma. The Medical Expenditure Panel Survey data from 1996-1999 on 3-11 year old U.S. children with asthma (N=784) were used. The findings of multilevel models of perceived burden indicated unfavorable trajectories among those families who had public health insurance. Asthma control activities were associated with favorable trajectories of both perceived and objectively measured burden. These findings emphasized the significance of asthma control and access to high quality and stable health care services as health policy targets.
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Does access to care equal asthma control in school-age children? J Allergy Clin Immunol 2009; 124:381-3. [PMID: 19596141 DOI: 10.1016/j.jaci.2009.05.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 05/28/2009] [Accepted: 05/29/2009] [Indexed: 11/20/2022]
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Stevens GD, Pickering TA, Seid M, Tsai KY. Disparities in the national prevalence of a quality medical home for children with asthma. Acad Pediatr 2009; 9:234-41. [PMID: 19608124 DOI: 10.1016/j.acap.2009.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 01/15/2009] [Accepted: 01/29/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to examine sociodemographic disparities in having a quality medical home among a nationally representative sample of children with asthma. METHODS The study examined data from the 2003 National Survey of Children's Health to identify 8360 children aged 2-17 years with asthma. Risk factors including nonwhite race/ethnicity, income <200% of the federal poverty level (FPL), uninsured, parent education less than high school, and non-English language, were examined individually and as a profile of risk in relation to a quality medical home. Fourteen questions were used to measure 5 medical home features: access, continuity, comprehensiveness, family-centered care, and coordination. A poorer quality medical home was defined as < or =66 on a 100-point scale-corresponding to the feature being present less than "usually"-for each feature and for an overall score. RESULTS Before and after adjustment for demographics and asthma difficulties, most risks except less than high school parent education were related to a poorer quality medical home. Uninsured children had the highest odds of a poorer quality medical home overall (adjusted odds ratio [OR] 5.19, 95% confidence interval [CI] 3.52-7.65) and across most features, except for coordination. Children experiencing 3+ risks had 8.56 times the odds of a poorer quality medical home overall (95% CI 4.95-14.78) versus zero risks. CONCLUSIONS This study demonstrates large national disparities in a quality medical home for children with asthma. That disparities were most prevalent for the uninsured (insurance being a modifiable risk factor) suggests increasing coverage is essential to assuring that children obtain a quality medical home.
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Affiliation(s)
- Gregory D Stevens
- Center for Community Health Studies, Department of Family Medicine, University of Southern California Keck School of Medicine, 1000 South Fremont Ave, Unit #80, Alhambra, California 91803, USA.
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Fiscella K, Kitzman H. Disparities in academic achievement and health: the intersection of child education and health policy. Pediatrics 2009; 123:1073-80. [PMID: 19255042 DOI: 10.1542/peds.2008-0533] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recent data suggest that that the United States is failing to make significant progress toward the Healthy People 2010 goal of eliminating health disparities. One missing element from the US strategy for achieving this goal is a focus on gaps in child development and achievement. Academic achievement and education seem to be critical determinants of health across the life span and disparities in one contribute to disparities in the other. Despite these linkages, national policy treats child education and health as separate. Landmark education legislation, the No Child Left Behind Act of 2001, is due for Congressional reauthorization. It seeks to eliminate gaps in academic child achievement by 2014. It does so by introducing accountability for states, school districts, and schools. In this special article, we review health disparities and contributors to child achievement gaps. We review changes in achievement gaps over time and potential contributors to the limited success of the No Child Left Behind Act of 2001, including its unfunded mandates and unfounded assumptions. We conclude with key reforms, which include addressing gaps in child school readiness through adequate investment in child health and early education and reductions in child poverty; closing the gap in child achievement by ensuring equity in school accountability standards; and, importantly, ensuring equity in school funding so that resources are allocated on the basis of the needs of the students. This will ensure that schools, particularly those serving large numbers of poor and minority children, have the resources necessary to promote optimal learning.
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Affiliation(s)
- Kevin Fiscella
- University of Rochester, 1381 South Ave, Rochester, NY 14620, USA.
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Cummings JR, Lavarreda SA, Rice T, Brown ER. The effects of varying periods of uninsurance on children's access to health care. Pediatrics 2009; 123:e411-8. [PMID: 19254977 DOI: 10.1542/peds.2008-1874] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Many studies have documented the adverse consequences of uninsurance for children, but less is known about the differential effects of varying periods of uninsurance. This study examines the relative effects of varying periods of uninsurance (uninsured for 1-4 months, 5-11 months, or all year) on children's access to care. METHODS Using data from the 2005 California Health Interview Survey Children's File (ages 0-11), we estimated logistic regressions to examine the effect of insurance status on 6 measures of health care access, controlling for child demographics, child health status, family characteristics, and urban residence. Indicators for insurance status included the following categories: (1) privately insured all year (reference); (2) Medicaid all year; (3) State Children's Health Insurance Program all year; (4) uninsured for 1 to 4 months; (5) uninsured for 5 to 11 months; (6) uninsured all year; and (7) other insurance all year. RESULTS We found that children who experience short spells of uninsurance (1-4 months) are less likely to have a usual source of care and are more likely to experience delays in needed care than those with continuous private or public insurance. The consequences are even worse for children who experience more substantial periods of uninsurance, because they are also less likely to receive preventive care (well-child visits and flu shots) or visit the doctor during the year and are more likely to experience delays in receiving needed medical care and prescriptions than those with continuous coverage. The Medicaid program and State Children's Health Insurance Program in California both seem to have ensured levels of health care access similar to that obtained by children with year-round private coverage. CONCLUSIONS These findings highlight the benefits gained through continuous health insurance, whether public or private. Public policies should be adopted to ensure continuity of coverage and retention in public insurance programs.
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Affiliation(s)
- Janet R Cummings
- BA, Department of Health Services, School of Public Health, Campus Box 951772, Los Angeles, CA 90095-1772, USA.
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Current Opinion in Pulmonary Medicine. Current world literature. Curr Opin Pulm Med 2009; 15:79-87. [PMID: 19077710 DOI: 10.1097/mcp.0b013e32831fb1f3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Genel M, McCaffree MA, Hendricks K, Dennery PA, Hay WW, Stanton B, Szilagyi PG, Jenkins RR. A National Agenda for America's Children and Adolescents in 2008: recommendations from the 15th Annual Public Policy Plenary Symposium, annual meeting of the Pediatric Academic Societies, May 3, 2008. Pediatrics 2008; 122:843-9. [PMID: 18829810 DOI: 10.1542/peds.2008-2143] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Myron Genel
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA.
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