Hospitalizations for asthma in an urban population: 1995–1999

Improving Asthma Outcomes During Pregnancy in Underserved Communities

It is known that poor asthma control is common in pregnancy, and asthma in general disproportionally affects underserved communities. However, there is a paucity of data examining strategies to improve asthma control specifically among pregnant women from vulnerable populations. Identified barriers to optimal asthma care in other underserved groups include health literacy, financial constraints, cultural differences, and poor environmental controls. These deficiencies may also be targets for multimodal interventions geared toward improving asthma outcomes for underserved women during pregnancy.

Improving Asthma Symptoms Among Inner-City Women During Pregnancy: A Prospective Cohort Intervention

BACKGROUND

It is unknown how active asthma management influences symptom control among inner-city pregnant women who have unique exposures and socioeconomic limitations affecting their care.

OBJECTIVE

To assess the impact of an integrated subspecialty intervention composed of education and monitoring on asthma control among underserved women in an antenatal clinic setting.

METHODS

We conducted a prospective cohort study of pregnant asthmatic patients participating in a subspecialty clinic integrated into routine prenatal care. We compared baseline characteristics and objective measurements of asthma control between women at an initial visit and those who were evaluated in at least one follow-up. For follow-up, we measured symptom control at successive visits and the incidence of asthma-related complications.

RESULTS

Among 85 women enrolled, 53 (62.4%) returned for at least one follow-up visit. Mean baseline Asthma Control Test scores were similarly low (≤19) between groups (one or more follow-up and no follow-up), as were self-administered Asthma Quality of Life Questionnaire scores (<4.7). A total of 72 women had inadequate asthma control resulting in step-up therapy after the initial visit (84.7%). There was a significant increase in ACT scores between the initial and first follow-up visits. For those with an intervening self-administered Asthma Quality of Life Questionnaire, there was also a significant increase by 1.39 ± 0.67 (P = .0003).

CONCLUSIONS

We found that uncontrolled asthma is common among urban women seeking routine obstetric care. Our results suggest that even one interventional visit can result in significant improvement in asthma control. Further investigation into mechanisms for optimizing treatment strategies may improve the quality of asthma care during pregnancy in this underserved population.

Update in Pediatric Asthma: Selected Issues

Asthma is a complex condition that affects 14% of the world's children and the approach to management includes both pharmacologic as well as non-pharmacologic strategies including attention to complex socioeconomic status phenomena. After an historical consideration of asthma, allergic and immunologic aspects of asthma in children and adolescents are presented. Concepts of socioeconomic aspects of asthma are considered along with environmental features and complications of asthma disparities. Also reviewed are links of asthma with mental health disorders, sleep disturbances and other comorbidities. A stepwise approach to asthma management is discussed that includes pharmacologic and non-pharmacologic strategies in the pediatric population. The role of immunotherapy and use of various immunomodulators are considered as well.

Trends and predictors of hospitalization after emergency department asthma visits among U.S. Adults, 2006-2014

Background: Asthma hospitalizations are an ambulatory care-sensitive condition; a majority originate in emergency departments (EDs).Objective: Describe trends and predictors of adult asthma hospitalizations originating in EDs.Methods: Observational study of ED visits resulting in hospitalization using a nationally representative sample. We tested trend in hospitalization rates from 2006 to 2014 using logistic regression, then assessed the association between hospitalization rates and patient and hospital characteristics using hierarchical multivariable regression accounting for hospital-level clustering.Results: Total ED asthma visits increased 15% from 2006 to 2014, from 1.06 to 1.22 million, while the likelihood of hospitalization decreased (20.9-18.2%, p < 0.01). Adjusting for increased asthma prevalence, ED visit rates and hospitalization rates decreased by 10 and 21%, respectively. Hospitalization was independently associated with older age, female gender (OR = 1.23, 95% CI 1.20-1.26), higher Charlson score (OR = 1.99, 95% CI 1.97-2.01), Medicaid (OR = 1.05, 95% CI 1.01-1.08) and Medicare (OR = 1.26, 95% CI 1.22-1.31) insurance, and trauma centers (OR = 1.34, 95% CI 1.12-1.60). Hospitalization was less likely for uninsured visits (OR = 0.7, 95% CI 0.67-0.73), lower income areas (OR = 0.89, 95% CI 0.85-0.93), non-metropolitan teaching hospitals (OR = 0.83, 95% CI 0.71-0.96), Midwestern (OR = 0.84, 95% CI 0.69-1.01) or Western regions (OR 0.69, 95% CI 0.56-0.83). Unmeasured hospital-specific effects account for 15.8% of variability in hospital admission rates after adjusting for patient and hospital factors.Conclusions: Total asthma ED visits increased, but prevalence-adjusted ED visits, and ED hospitalization rates have declined. Uninsured patients have disproportionately more ED visits but 30% lower odds of hospitalization. Substantial variation implies unmeasured clinical, social and environmental factors accounting for hospital-specific differences in hospitalization.

A new socioeconomic status measure for vaccine research in children using individual housing data: a population-based case-control study

Background

We recently developed HOUSES, an individual housing-based socioeconomic status (SES) measurement for health disparities research. We assessed whether HOUSES was associated with risk of pertussis and pertussis vaccine up-to-date status in children.

Methods

The study utilized a previous population-based case-control study cohort assembled during the 2004–2005 pertussis outbreak. We collected data on pertussis vaccine status (up-to-date status) at the time of the index date. Using a z-score for housing value, actual square footage, and numbers of bedrooms and bathrooms, HOUSES was formulated in continuous variable and categorized into quartiles. Vaccine up-to-date status was compared among subjects with different SES as measured by HOUSES using a chi-square test and logistic regression models.

Results

Of the 391 eligible pediatric subjects (median age of 13.1 years with male sex of 55 %), 363 (93 %) were successfully geocoded to formulate HOUSES index. HOUSES was not associated with the risk of pertussis (p = 0.82). Pertussis vaccine up-to-date statuses were 79, 86, 83, and 94 % for children in the first (the lowest SES), second, third, and fourth quartiles of HOUSES, respectively (p = 0.03). HOUSES as a continuous variable was associated with pertussis vaccine up-to-date status (adjusted OR: 1.15 per increment of one unit of HOUSES, 95 % CI: 1.04–1.27, p = 0.008).

Conclusion

While HOUSES is not associated with the risk of pertussis, it predicts vaccine up-to-date status among children with different SES. HOUSES may be a useful tool for vaccine delivery research among children.

A novel housing-based socioeconomic measure predicts hospitalisation and multiple chronic conditions in a community population

BACKGROUND

Socioeconomic status (SES) is an important predictor for outcomes of chronic diseases. However, it is often unavailable in clinical data. We sought to determine whether an individual housing-based SES index termed HOUSES can influence the likelihood of multiple chronic conditions (MCC) and hospitalisation in a community population.

METHODS

Participants were residents of Olmsted County, Minnesota, aged >18 years, who were enrolled in Mayo Clinic Biobank on 31 December 2010, with follow-up until 31 December 2011. Primary outcome was all-cause hospitalisation over 1 calendar-year. Secondary outcome was MCC determined through a Minnesota Medical Tiering score. A logistic regression model was used to assess the association of HOUSES with the Minnesota tiering score. With adjustment for age, sex and MCC, the association of HOUSES with hospitalisation risk was tested using the Cox proportional hazards model.

RESULTS

Eligible patients totalled 6402 persons (median age, 57 years; 25th-75th quartiles, 45-68 years). The lowest quartile of HOUSES was associated with a higher Minnesota tiering score after adjustment for age and sex (OR (95% CI) 2.4 (2.0 to 3.1)) when compared with the highest HOUSES quartile. Patients in the lowest HOUSES quartile had higher risk of all-cause hospitalisation (age, sex, MCC-adjusted HR (95% CI) 1.53 (1.18 to 1.98)) compared with those in the highest quartile.

CONCLUSIONS

Low SES, as assessed by HOUSES, was associated with increased risk of hospitalisation and greater MCC health burden. HOUSES may be a clinically useful surrogate for SES to assess risk stratification for patient care and clinical research.

A novel measure of socioeconomic status using individual housing data to assess the association of SES with rheumatoid arthritis and its mortality: a population-based case-control study

OBJECTIVES

To assess whether HOUSES (HOUsing-based index of socioeconomic status (SES)) is associated with risk of and mortality after rheumatoid arthritis (RA).

DESIGN

We conducted a population-based case-control study which enrolled population-based RA cases and their controls without RA.

SETTING

The study was performed in Olmsted County, Minnesota.

PARTICIPANTS

Study participants were all residents of Olmsted County, Minnesota, with RA identified using the 1987 American College of Rheumatology criteria for RA from 1 January 1988, to 31 December 2007, using the auspices of the Rochester Epidemiology Project. For each patient with RA, one control was randomly selected from Olmsted County residents of similar age and gender without RA.

PRIMARY AND SECONDARY OUTCOME MEASURE

The disease status was RA cases and their matched controls in relation to HOUSES as an exposure. As a secondary aim, post-RA mortality among only RA cases was an outcome event. The associations of SES measured by HOUSES with the study outcomes were assessed using logistic regression and Cox models. HOUSES, as a composite index, was formulated based on a summed z-score for housing value, square footage and number of bedrooms and bathrooms.

RESULTS

Of the eligible 604 participants, 418 (69%) were female; the mean age was 56±15.6 years. Lower SES, as measured by HOUSES, was associated with the risk of developing RA (0.5±3.8 for controls vs -0.2±3.1 for RA cases, p=0.003), adjusting for age, gender, calendar year of RA index date, smoking status and BMI. The lowest quartile of HOUSES was significantly associated with increased post-RA mortality compared to higher quartiles of HOUSES (HR 1.74; 95% CI 1.10 to 2.74; p=0.017) in multivariate analysis.

CONCLUSIONS

Lower SES, as measured by HOUSES, is associated with increased risk of RA and mortality after RA. HOUSES may be a useful tool for health disparities research concerning rheumatological outcomes when conventional SES measures are unavailable.

Application of a novel socioeconomic measure using individual housing data in asthma research: an exploratory study

BACKGROUND

A housing-based socioeconomic index (HOUSES) was previously developed to overcome an absence of socioeconomic status (SES) measures in common databases. HOUSES is associated with child health outcomes in Olmsted County, Minnesota, USA, but generalisability to other geographic areas is unclear.

AIM

To assess whether HOUSES is associated with asthma outcomes outside Olmsted County, Minnesota, USA.

METHODS

Using a random sample of children with asthma from Sanford Children's Hospital, Sioux Falls, SD, USA, asthma status was determined. The primary outcome was asthma control status using Asthma Control Test and a secondary outcome was risk of persistent asthma. Home address information and property data were merged to formulate HOUSES. Other SES measures were examined: income, parental education (PE), Hollingshead and Nakao-Treas index.

RESULTS

Of a random sample of 200 children, 80 (40%) participated in the study. Of those, 13% had poorly controlled asthma. Addresses of 94% were matched with property data. HOUSES had moderate-good correlation with other SES measures except PE. Poor asthma control rates were 31.6%, 4.8% and 5.6% for patients in the lowest, intermediate and highest tertiles of HOUSES, respectively (P=0.023). HOUSES as a continuous variable was inversely associated with poorly controlled asthma (adjusted odds ratio (OR)=0.21 per 1 unit increase of HOUSES, 95% confidence interval (CI), 0.05-0.89, P=0.035). HOUSES as a continuous variable was inversely related to risk of persistent asthma (OR: 0.36 per 1 unit increase of HOUSES, 95% CI, 0.12-1.04, P=0.06).

CONCLUSIONS

HOUSES appears to be generalisable and available as a measure of SES in asthma research in the absence of conventional SES measures.

Asthma control, cost and race: results from a national survey

OBJECTIVE

Although interventions have been shown to alleviate symptoms in most patients suffering from asthma, only one-third of asthma patients have disease that is well-controlled. The purpose of this study is to investigate whether partly and uncontrolled asthmas are associated with increased costs for asthma-related healthcare utilization compared to well-controlled asthma and to determine whether these associations differed across racial groups.

METHODS

We classified respondents from the Asthma Insights and Management survey into those with well-, partly and uncontrolled asthma and compared utilization of healthcare services and costs among these groups, as well as between whites and non-whites.

RESULTS

Respondents categorized as having asthma that was not well-controlled reported lower income levels, higher rates of unemployment and more trouble paying for healthcare; similar results were found in analyses stratified by race. Patients whose asthma was partly or uncontrolled had greater use of asthma-related medications and medical services compared to patients whose asthma was well-controlled. Total unadjusted and adjusted costs were greater in patients whose asthma was classified as partly and uncontrolled. Similar results were found in analyses stratified on race. Across all levels of asthma control, non-whites had higher rates of utilization of emergency rooms and urgent care facilities and had greater rates of hospitalizations compared to whites.

CONCLUSIONS

Our findings indicate that patients with asthma that is not well-controlled utilized more healthcare resources and had greater medical costs, despite lacking of health insurance which may suggest less access to care.

African ancestry is a risk factor for asthma and high total IgE levels in African admixed populations

Characterization of genetic admixture of populations in the Americas and the Caribbean is of interest for anthropological, epidemiological, and historical reasons. Asthma has a higher prevalence and is more severe in populations with a high African component. Association of African ancestry with asthma has been demonstrated. We estimated admixture proportions of samples from six trihybrid populations of African descent and determined the relationship between African ancestry and asthma and total serum IgE levels (tIgE). We genotyped 237 ancestry informative markers in asthmatics and nonasthmatic controls from Barbados (190/277), Jamaica (177/529), Brazil (40/220), Colombia (508/625), African Americans from New York (207/171), and African Americans from Baltimore/Washington, D.C. (625/757). We estimated individual ancestries and evaluated genetic stratification using Structure and principal component analysis. Association of African ancestry and asthma and tIgE was evaluated by regression analysis. Mean ± SD African ancestry ranged from 0.76 ± 0.10 among Barbadians to 0.33 ± 0.13 in Colombians. The European component varied from 0.14 ± 0.05 among Jamaicans and Barbadians to 0.26 ± 0.08 among Colombians. African ancestry was associated with risk for asthma in Colombians (odds ratio (OR) = 4.5, P = 0.001) Brazilians (OR = 136.5, P = 0.003), and African Americans of New York (OR: 4.7; P = 0.040). African ancestry was also associated with higher tIgE levels among Colombians (β = 1.3, P = 0.04), Barbadians (β = 3.8, P = 0.03), and Brazilians (β = 1.6, P = 0.03). Our findings indicate that African ancestry can account for, at least in part, the association between asthma and its associated trait, tIgE levels.

Budesonide/formoterol pressurized metered-dose inhaler versus budesonide: a randomized controlled trial in black patients with asthma

OBJECTIVE

Concerns exist that responses to long-acting β(2)-adrenergic agonists in black patients may differ from the general population. The efficacy and safety of budesonide/formoterol (BUD/FM) pressurized metered-dose inhaler (pMDI) versus budesonide dry powder inhaler (BUD DPI) were evaluated in adolescent and adult black asthma patients.

METHODS

This 12-week, randomized, double-blind, multicenter, phase IV US study was conducted in 311 self-reported black patients aged ≥12 years with moderate to severe persistent asthma, previously receiving medium- to high-dose inhaled corticosteroid. After 2 weeks on BUD 90 μg × 2 inhalations twice daily (bid), symptomatic patients were randomized to BUD/FM 160/4.5 μg × 2 inhalations bid or BUD 180 μg × 2 inhalations bid.

RESULTS

Improvement in predose forced expiratory volume in 1 second from baseline to the treatment mean (primary variable) was greater with BUD/FM versus BUD (0.16 vs. 0.07 L; p = .008); this effect was also observed at weeks 2, 6, and end of treatment (p ≤ .032). Greater improvements (p < .001) in peak expiratory flow with BUD/FM versus BUD were seen at first measurement and maintained during 12 weeks (morning: 25.34 vs. 7.53 L/minute, respectively; evening: 21.61 vs. 7.67 L/minute, respectively); greater improvements in daily asthma symptom score and rescue medication use were also observed (p ≤ .039). Both treatments were well tolerated, with similar safety profiles.

CONCLUSIONS

In this population of black asthma patients, BUD/FM pMDI resulted in greater improvements in pulmonary function and asthma control versus BUD DPI, with similar safety profiles.

The Breathmobile program: a good investment for underserved children with asthma

BACKGROUND

The Breathmobile, a specialty-based mobile asthma clinic, provides free care to underserved children. The cost of symptom-free day (SFD) improvement in this population has not been previously reported.

OBJECTIVE

To examine the clinical impact and cost-effectiveness of the Baltimore Breathmobile.

METHODS

Existing computerized data were analyzed for Breathmobile patient visits between 2002 and 2007. All SFDs were calculated, and direct medical cost savings attributable to decreased emergency department visits and hospitalizations (after program utilization vs the previous year) were compared with annual operating costs. Incremental cost-effectiveness ratios were determined by calculating the incremental costs of Breathmobile care per additional SFD gained per child per year.

RESULTS

The analysis included 255 patients enrolled in the program for at least 1 year. Most participants were black (93.3%), and 54.9% were male. At baseline, patients reported a mean (SD) of 199 (118) SFDs in the year before enrollment. After 1 year in the program, patients had a mean (SD) improvement of 44 (9) SFDs. The program resulted in overall cost savings of $79.43 per SFD gained, with greater cost savings for children aged 5 to 11 years (-$116.84 per SFD gained) and those with intermittent asthma (-$126.71 per SFD gained).

CONCLUSIONS

The Baltimore Breathmobile program has demonstrated significant improvement in SFDs, with direct medical cost savings of the program outweighing the operational costs. These data support the need to continue to sustain and expand Breathmobile programs for children at high risk for asthma exacerbations and to conduct a randomized clinical trial to estimate the cost-effectiveness of the Breathmobile.