A childhood asthma severity scale: symptoms, medications, and health care visits

Ethnic variation in asthma healthcare utilisation and exacerbation: systematic review and meta-analysis

Background

Patients from ethnic minority groups (EMGs) frequently report poorer asthma outcomes; however, a broad synthesis summarising ethnic disparities is yet to be undertaken. What is the magnitude of ethnic disparities in asthma healthcare utilisation, exacerbations and mortality?

Methods

MEDLINE, Embase and Web of Science databases were searched for studies reporting ethnic variation in asthma healthcare outcomes (primary care attendance, exacerbation, emergency department (ED) visits, hospitalisation, hospital readmission, ventilation/intubation and mortality) between White patients and those from EMGs. Estimates were displayed using forest plots and random-effects models were used to calculate pooled estimates. We conducted subgroup analyses to explore heterogeneity, including by specific ethnicity (Black, Hispanic, Asian and other).

Results

65 studies, comprising 699 882 patients, were included. Most studies (92.3%) were conducted in the United States of America (USA). Patients from EMGs had evidence suggestive of lower levels of primary care attendance (OR 0.72, 95% CI 0.48-1.09), but substantially higher ED visits (OR 1.74, 95% CI 1.53-1.98), hospitalisations (OR 1.63, 95% CI 1.48-1.79) and ventilation/intubation (OR 2.67, 95% CI 1.65-4.31) when compared to White patients. In addition, we found evidence suggestive of increased hospital readmissions (OR 1.19, 95% CI 0.90-1.57) and exacerbation rates (OR 1.10, 95% CI 0.94-1.28) among EMGs. No eligible studies explored disparities in mortality. ED visits were much higher among Black and Hispanic patients, while Asian and other ethnicities had similar rates to White patients.

Conclusions

EMGs had higher secondary care utilisation and exacerbations. Despite the global importance of this issue, the majority of studies were performed in the USA. Further research into the causes of these disparities, including whether these vary by specific ethnicity, is required to aid the design of effective interventions.

Smartphone App for monitoring Asthma in children and adolescents

PURPOSE

The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them.

METHODS

The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights).

RESULTS

The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application.

CONCLUSIONS

Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients.

Introduction of a new paediatric asthma guideline: Effects on asthma control levels

BACKGROUND

In 2008, a new national paediatric asthma management guideline based on the international Global Initiative for Asthma (GINA) guideline was launched in the Netherlands. We studied whether asthma control and treatment regimens improved after introduction of the guideline by comparing survey data before and after the guideline introduction.

METHODS

Two comparable groups of children (6-16 years) with asthma were included before (2004) and after (2013) the introduction of the guideline. Children, parents and paediatricians completed questionnaires about asthma symptoms, medication and healthcare use. Spirometry was performed.

RESULTS

Data of 209 patients were analysed. Level of asthma control did not improve between 2004 and 2013 with a proportion of (partly) controlled asthmatics of 51% in 2004 and 59% in 2013 (p = 0.28). In 2013, paediatricians characterized 76% of children as (partly) controlled, while 59% of children was (partly) controlled according to GINA criteria (p < 0.05). Step-down treatment in controlled patients was more applied by paediatricians in 2013 compared to 2004 (from 8 to 40%, p < 0.05). Step-up treatment in uncontrolled patients did not improve.

CONCLUSIONS

Asthma control did not improve after the introduction of the new guideline. Compared to 2004, an improvement was observed in step-down treatment in patients with controlled disease.

Environmental measures in domicilliary interventions of asthmatic children

OBJECTIVE

To evaluate the impact of environmental interventions and lifestyle management on respiratory symptoms, concurrent changes in asthma management and whether any observed health benefit could be attributed to these interventions.

METHODS

A longitudinal single cohort pre-post study was conducted on children between 5–14 y with moderate to severe asthma in an outpatient clinic at Jamshedpur over 2 y. History was noted using the pre-intervention questionnaire covering a period of 3 mo prior to enrolment. Participants were followed for 6 mo post- intervention. A childhood asthma severity (CHAS) scale was made and statistical analysis such as Wilcoxon rank sum tests and Mcnemar’s test performed to validate the outcomes. Principal component analysis was performed to classify the participants having no, mild and severe symptoms.

RESULTS

There was significant reduction in symptoms and need for medical care post-intervention. Mean of the respiratory symptom score decreased from 7.4 to 2.4 (p < 0.0001) and mean of the health care utilization score decreased from 4.1 to 1.7 (p < 0.0004) in the wilcoxon rank sum tests. Mcnemar’s test was used for the analysis of individual item of the asthma symptoms. A significant reduction in wheeze and cough (p < 0.001), slowing down physical activity (p < 0.001), diurnal symptoms (p < 0.000), school absence (p < 0.000), rescue therapy requirement (p < 0.1) and hospitalization (p < 0.000) was seen. PCA was used successfully to classify the participants on the basis of their severity of asthma.

CONCLUSIONS

Respiratory symptoms decreased significantly among asthmatic children following environmental interventions.

Access to and use of asthma health services among Latino children: the Rhode Island-Puerto Rico asthma center study

This study determines asthma-related health care access and utilization patterns for Latino children of Puerto Rican and Dominican origin residing in Rhode Island (RI) and Latino children residing in Puerto Rico (Island). Data included 804 families of children with persistent asthma recruited from clinics. Island children were less likely to receive regular asthma care and care from a consistent provider and more likely to have been to the emergency department and hospitalized for asthma than RI children. Island children were 2.33 times more likely to have used the emergency department for asthma compared with RI non-Latino White (NLW) children. Latino children residing in both Island and RI were less likely to have used specialty care and more likely to have had a physician visit for asthma in the past year than RI NLW children. The differences might reflect the effects of the different delivery systems on pediatric health care utilization and asthma management.

A simulation model approach to analysis of the business case for eliminating health care disparities

BACKGROUND

Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers.

METHODS

To illustrate a method for calculating an employer business case for disparity reduction and to compare the business case in two clinical areas, we conducted analyses of the direct (medical care costs paid by employers) and indirect (absenteeism, productivity) effects of eliminating known racial/ethnic disparities in mammography screening and appropriate medication use for patients with asthma. We used Markov simulation models to estimate the consequences, for defined populations of African-American employees or health plan members, of a 10% increase in HEDIS mammography rates or a 10% increase in appropriate medication use among either adults or children/adolescents with asthma.

RESULTS

The savings per employed African-American woman aged 50-65 associated with a 10% increase in HEDIS mammography rate, from direct medical expenses and indirect costs (absenteeism, productivity) combined, was $50. The findings for asthma were more favorable from an employer point of view at approximately $1,660 per person if raising medication adherence rates in African-American employees or dependents by 10%.

CONCLUSIONS

For the employer business case, both clinical scenarios modeled showed positive results. There is a greater potential financial gain related to eliminating a disparity in asthma medications than there is for eliminating a disparity in mammography rates.

Cockroach exposure independent of sensitization status and association with hospitalizations for asthma in inner-city children

BACKGROUND

Children with asthma living in urban environments experience disproportionately high asthma hospitalization rates. Excessive exposure to perennial allergens, including cockroach and house dust mite (HDM), have been implicated, but data are limited.

OBJECTIVE

To examine the relation between cockroach and HDM exposure and measures of asthma morbidity and health care utilization.

METHODS

Participants included 86 atopic asthmatic children living in New Orleans, Louisiana. Sensitization status was determined by means of serum specific IgE testing, and vacuum dust samples were collected for allergen analysis. Logistic regression analysis was used to assess the odds of persistent wheezing, emergency department visits, and asthma hospitalization in those with high vs low levels of allergen exposure.

RESULTS

Approximately 44% and 40% of children were exposed to Bla g 1 levels greater than 2 U/g and HDM levels greater than 2 μg/g, respectively, and 24% reported at least 1 hospitalization in the previous 4 months. The median Bla g 1 level was significantly higher in the homes of children hospitalized compared with those with no hospital admissions (7.2 vs 0.8 U/g). In multivariable models, the odds of hospitalization were significantly higher in children exposed to Bla g 1 levels greater than 2 U/g (adjusted odds ratio, 4.2; 95% confidence interval, 1.24-14.17), independent of sensitization status. Exposure to HDMs was not associated with any measure of morbidity.

CONCLUSIONS

Exposure to cockroach allergen was strongly associated with increased hospitalization in children with asthma. This effect cannot be explained entirely by IgE-mediated inflammation. Controlled interventional trials are needed to determine whether isolated cockroach abatement improves asthma control.

Disparities in asthma medication dispensing patterns: the case of pediatric asthma in Puerto Rico

BACKGROUND

Disparities exist in asthma medication dispensing between children with public insurance and those with private insurance under a Managed Care Medicaid system in Puerto Rico.

OBJECTIVES

Island-wide medical claims data were used to examine the extent to which differences between the private and public health care sectors affect medication dispensing and health care utilization among asthmatic children.

METHODS

Children 3-18 years old with at least one service claim [outpatient, hospitalization, or emergency department (ED) visit] for asthma or reactive airway disease from 2005 to 2006 were selected. Chi-square analyses compared medication dispensing and health care utilization between the public and private sectors. Negative binomial regression identified factors associated with the mean dispensing rate of prescriptions for anti-inflammatory controller medication (CM).

RESULTS

Private insurance families (n = 28,088) were dispensed significantly more CM (48.3% vs. 12.0%) and quick relief medication (47.4% vs. 44.6%) than public insurance families (n = 13,220). The dispensing of inhaled corticosteroids (24.4% vs. 6.7%) and leukotriene modifiers and cromolyn (31.4% vs. 5.7%) was dramatically higher in the private sector. In contrast, emergency room use was significantly higher among public insurance children (51.7% vs. 13.8%). Multivariate analysis showed that age, number of β-agonists, and type of insurance was associated with CM dispensing; private insurance showed the greatest effect.

CONCLUSION

Asthmatic Puerto Rican children enrolled in public insurance were significantly less likely to be dispensed CM than children with private insurance; suggesting that under-treatment of public insured children may substantially contribute to increased asthma morbidity in this population as evidenced by significantly higher rates of ED visits.

CAPSULE SUMMARY

A disparity exists in asthma medication dispensing between children with public insurance compared with those with private insurance under a Managed Care Medicaid system in Puerto Rico. If asthma disparities in medication dispensing are to be reduced, then a better understanding of the complex ways in which multiple variables related to the health care system policies, socioeconomic factors, family and provider interactions, as well as the relative weight that each one contributes to the observed inequalities is needed.

Do family mealtime interactions mediate the association between asthma symptoms and separation anxiety?

BACKGROUND

Respiratory problems have been shown to be associated with the development of panic anxiety. Family members play an essential role for children to emotionally manage their symptoms. This study aimed to examine the relation between severity of respiratory symptoms in children with asthma and separation anxiety. Relying on direct observation of family interactions during a mealtime, a model is tested whereby family interactions mediate the relation between asthma severity and separation anxiety symptoms.

METHODS

Sixty-three children (ages 9-12 years) with persistent asthma were interviewed via the Diagnostic Interview Schedule for Children IV; family interactions were assessed via direct observation of a mealtime; primary caregivers completed the Childhood Asthma Severity Scale; youth pulmonary function was ascertained with pre- and post-bronchodilator spirometry; adherence to asthma medications was objectively tracked for six weeks.

RESULTS

Poorer pulmonary function and higher functional asthma severity were related to higher numbers of separation anxiety symptoms. Controlling for medication adherence, family interaction patterns mediated the relationship between poorer pulmonary function and child separation anxiety symptoms.

CONCLUSIONS

Family mealtime interactions may be a mechanism by which respiratory disorders are associated with separation anxiety symptoms in children, potentially through increasing the child's capacity to cognitively frame asthma symptoms as less threatening, or through increasing the child's sense of security within their family relationships.

Conundrums in childhood asthma severity, control, and health care use: Puerto Rico versus Rhode Island

BACKGROUND

The lifetime prevalence of self-reported asthma among Puerto Ricans is very high, with increased asthma hospitalizations, emergency department visits, and mortality rates. Differences in asthma severity between the mainland and island, however, remain largely unknown.

OBJECTIVE

We sought to characterize differences in asthma severity and control among 4 groups: (1) Island Puerto Ricans, (2) Rhode Island (RI) Puerto Ricans, (3) RI Dominicans, and (4) RI whites.

METHODS

Eight hundred five children aged 7 to 15 years completed a diagnostic clinic session, including a formal interview, physical examination, spirometry, and allergy testing. Using a visual grid adapted from the Global Initiative for Asthma, asthma specialists practicing in each site determined an asthma severity rating. A corresponding level of asthma control was determined by using a computer algorithm.

RESULTS

Island Puerto Ricans had significantly milder asthma severity compared with RI Puerto Ricans, Dominicans, and whites (P < .001). Island Puerto Ricans were not significantly different from RI whites in asthma control. RI Puerto Ricans showed a trend toward less control compared with island Puerto Ricans (P = .061). RI Dominicans had the lowest rate of controlled asthma. Paradoxically, island Puerto Ricans had more emergency department visits in the past 12 months (P < .001) compared with the 3 RI groups.

CONCLUSIONS

Potential explanations for the paradoxic finding of milder asthma in island Puerto Ricans in the face of high health care use are discussed. Difficulties in determining guideline-based composite ratings for severity versus control are explored in the context of disparate groups.

Asthma severity and child quality of life in pediatric asthma: a systematic review

OBJECTIVE

To systematically review evidence of asthma severity as a correlate of child quality of life (QOL) in pediatric asthma.

METHODS

Online bibliographic databases (PsycINFO, PsycARTICLES, and MEDLINE) were used to identify relevant studies that specifically considered the relationship between asthma severity and child QOL.

RESULTS

Fourteen studies matching inclusion and exclusion criteria were reviewed. Asthma severity was significantly related to child QOL in nine of these studies. Informant of QOL and type of QOL measure were found to influence the strength of the relationship between severity and child QOL in pediatric asthma.

CONCLUSIONS

Findings suggest that asthma severity is a correlate of child QOL. Children whose asthma symptoms are not well-managed are likely to experience an impaired level of QOL. Findings also suggest the need to utilize asthma-specific QOL measures and an informant of QOL other than the child's parent in order to receive the most accurate information about the child's level of functioning.

PRACTICE IMPLICATIONS

Researchers and healthcare providers basing clinical outcomes on QOL assessments should consider asthma severity in their evaluations. Further, researchers and healthcare providers should recognize the continued need to reduce asthma severity and improve asthma symptom control in their attempts to improve the QOL of children with asthma.

The role of caregivers' depressive symptoms and asthma beliefs on asthma outcomes among low-income Puerto Rican children

OBJECTIVE

To examine the relationship between depressive symptoms and asthma beliefs (self-efficacy and empowerment), child asthma outcomes, and caregiver's quality of life among Puerto Rican caregivers of children with asthma.

METHODS

The caregivers of 221 children with persistent bronchial asthma were stratified into those with no/low or high levels of depressive symptoms. Differences between the groups in caregiver self-efficacy, family empowerment, child asthma outcomes, and quality of life were examined.

RESULTS

Caregivers with more depressive symptoms reported lower self-efficacy, less empowerment, less symptom-free days and nights for their children, and a lower quality of life compared to caregivers with no or fewer depressive symptoms.

CONCLUSIONS

Depressive symptoms among Puerto Rican caregivers were associated with asthma beliefs, children's asthma symptoms, and caregiver quality of life. Our findings reinforce the importance of physician screening skills in recognizing caregiver depression in parents of asthma patients.

Actual asthma control in a paediatric outpatient clinic population: do patients perceive their actual level of control?

Several epidemiological studies described poor asthma control in children. However, the diagnosis of childhood asthma in these studies is uncertain, and asthma control in children of an outpatient clinic population during treatment by a paediatrician is unknown. (1) to investigate the hypothesis that asthma control in a paediatric outpatient clinic population is better than epidemiological surveys suggest; (2) to find possible explanations for suboptimal asthma control. Asthmatic children aged 6-16 years, known for at least 6 months by a paediatrician at the outpatient clinic, were selected. During a normal visit, both the responsible physicians and parent/children completed a standardised questionnaire about asthma symptoms, limitation of daily activities, treatment, asthma attacks and emergency visits. Overall, excellent asthma control of 8.0% in this study was not significantly better than of 5.8% in the European AIR study (Chi-square, p = 0.24). Separate GINA goals like minimal chronic symptoms and no limitation of activities were better met in our study. Good to excellent controlled asthma was perceived by most children/parents (83%), but was less frequently indicated by the paediatrician (73%), or by objective criteria of control (45%) (chi-square, p = 0.0001). The agreement between patient-perceived and doctor assessed control was low, but improved in poorly controlled children. Patients were not able to perceive the difference between 'excellent asthma control' and 'good control' (p = 0.881).Too little children with uncontrolled disease got step-up of their asthma treatment. Although separate GINA goals like 'minimal chronic symptoms' and 'no limitation of activities' were significantly better in our study, overall, asthma control in this outpatient clinic population, treated by a paediatrician, was not significantly better than in the European AIR study. Poorly controlled disease was related to several aspects of asthma management, which are potentially accessible for improvements.

Inhaled corticosteroid use in asthmatic children receiving Ohio Medicaid: trend analysis, 1997-2001

BACKGROUND

In 1997, national guidelines emphasized that inhaled corticosteroids (ICSs) are key therapy for individuals with all classes of persistent asthma, including children.

OBJECTIVE

To examine the effect of these guidelines via time-trend analysis of ICS dispensation among children with asthma and Ohio Medicaid insurance.

METHODS

A retrospective cross-sectional analysis by yearly cohorts was performed. From January 1, 1997, to December 31, 2001, all children from birth to the age of 18 years with 6 months of Ohio Medicaid enrollment or more, 1 or more asthma diagnoses associated with a provider claim, and 1 or more prescription claims for an asthma medication in a given calendar year were identified using claims data. The daily beclomethasone equivalent (BME) dose, the daily albuterol equivalent dose, and asthma-related health care use were calculated for each child within each yearly cohort. A time-trend regression analysis of subjects enrolled in all 5 years examined factors associated with BME.

RESULTS

A total of 77,557 children met the study criteria. Among the 1,475 children enrolled during all 5 years, year of enrollment was a positive independent predictor of BME after adjustment for age, race, sex, systemic steroid bursts, albuterol equivalent dose, and health care use (P < .001).

CONCLUSIONS

The daily BME dose significantly increased for children with asthma insured by Ohio Medicaid from 1997 to 2001. However, the percentages of children receiving both ICS and a therapeutic BME dose were alarmingly low. The mean BME dose was particularly low among children with 1 or more emergency department visits, no hospitalizations, and 3 or fewer physician visits for asthma per year, suggesting that broader efforts to target this group are needed.

Effect of pregnancy and stage of pregnancy on asthma severity: a systematic review

Although pregnancy is purported to affect maternal asthma, the literature has not been reviewed systematically. The purpose of this systematic review was to determine, among pregnant women with asthma, whether pregnancy and stage of pregnancy influence maternal asthma severity. Six electronic databases were searched in January 2003 for prospective studies of currently asthmatic, pregnant women who were enrolled before the third trimester and assessed with objective measures of asthma severity or validated severity scales. Three studies reported 54 pregnant women with asthma who met the inclusion criteria. The most valid study indicated that bronchial hyperresponsiveness to methacholine improved between preconception and pregnancy in 69% of the women, although it deteriorated in 31% of the women. Further, this improvement peaked in the second trimester, reverted after delivery, and was greatest among those women who were most hyperresponsive initially. Lung function also showed a trend towards improvement during pregnancy that was not significant. Large, well-conducted population-based studies that explore different aspects of asthma severity are needed to substantiate these preliminary results.

Determinants of physical fitness in children with asthma

RATIONALE

This study was designed to examine the relationships among weight, asthma severity, physical activity, and aerobic fitness in children with asthma.

SUBJECTS AND METHODS

Sixty-four asthmatic children 8 to 12 years old (53% female) were assessed while attending a summer asthma camp. Measures included height and weight, spirometry, histamine bronchial provocation challenge, maximal aerobic power, and questionnaires to quantify habitual activity, perceived activity limitations due to asthma, perceived competence in physical activity, and attitudes toward physical activity. Asthma severity was determined from spirometric indices (forced expiratory volume during the first second), degree of airway hyperresponsiveness, and amount of medication prescribed.

RESULTS

There was no correlation between asthma severity and aerobic fitness. Only perceived competence at physical activity was found to have a significant correlation with aerobic fitness. Appropriate-weight, overweight, or obese (defined by body mass index) children all had similar results for maximum aerobic power and level of habitual activity. However, overweight or obese children reported greater limitation of physical activity. Their asthma-impairment scores were higher than the scores of appropriate-weight peers, although standard measures of pulmonary function were no different among groups. The higher asthma-severity scores were related to greater medication needs in the overweight or obese children with asthma.

CONCLUSIONS

Lower maximum aerobic power in asthmatic children is related more to how capable they perceive themselves than to asthma severity. Overweight asthmatic children experience greater limitation of physical activity and thus are prescribed more medication, although by standard measures of asthma severity, they are very similar to normal-weight peers with asthma. Efforts should be directed at understanding the reasons responsible for reduced exercise tolerance before escalating pharmacologic treatment.

Childhood asthma, chronic illness, and psychiatric disorders

Asthma is a serious and vexing problem for many children and their families. Asthma, like most syndromes, has many symptoms and potential causes and effects. Studies have shown that pediatric asthma is associated with psychiatric disorders, but the specificity and temporality of these relations is not well known. This study examined the associations between any and specific psychiatric disorders and both childhood asthma and other childhood chronic illnesses. The study used the Methods for the Epidemiology of Child and Adolescent Mental Disorders data, a four-site, community-based study of 1,285 pairs of youths and caretakers. Psychiatric disorders were assessed using the Diagnostic Interview Schedule for Children (DISC 2.3). Methods for the Epidemiology of Child and Adolescent Mental Disorders was also used to assess individual characteristics, parental reports of asthma, and other chronic illnesses. Asthma and 'other' chronic illnesses were associated with different psychiatric disorders. In particular, having a history of asthma was associated with having an anxiety disorder, after adjustment for potential confounding, but was not associated with having an affective disorder. Having a chronic illness other than asthma or cancer was associated with having any affective disorder and dysthymia but not anxiety disorder. These results call for more mechanistic research that explores the specific relations between childhood anxiety disorder and asthma and between affective disorder and other pediatric chronic illnesses.

Impact of site of care, race, and Hispanic ethnicity on medication use for childhood asthma

OBJECTIVE

To understand the importance of source of care and other factors that influence differences in asthma medication use by race and Hispanic ethnicity.

METHODS

The Childhood Asthma Severity Study provided 12-month, retrospective, parent-reported questionnaire data on a monthly basis for children ages </=12 years in a community sample of 1002 children and their families from Connecticut and Massachusetts. Medications considered included cromolyn, beta2-agonist, inhaled steroids, anticholinergics, theophylline, and systemic steroids. Information was available on demographics, insurance status, symptom severity, primary care contact, and provider practice types.

RESULTS

Black and Hispanic children received fewer beta2-agonists, and Hispanic children received fewer inhaled steroids than white children after adjusting for patients' race, age, gender, insurance status, symptom severity, number of primary care visits for asthma, number of urgent visits to the regular provider, family income, maternal education, and site of care. When multivariate analyses were restricted to patients in private practice, the significant association between Hispanic ethnicity and low inhaled steroid use persisted, whereas differences in beta2-agonist use by race and ethnicity changed little but became nonsignificant.

CONCLUSION

Even within private practices, patients' race and ethnicity are associated with clinician nonadherence to national guidelines. Programs to eliminate these disparities will need both to focus on site of care and to intervene at the provider and patient levels to be successful.

Use of health services by insurance status among children with asthma

OBJECTIVES

It is well known that asthmatic children receiving Medicaid use the emergency department (ED) more frequently than otherwise-insured asthmatic children. However, the extent to which this difference is attributable to provider characteristics, medication use, access to primary care, and symptomatology is poorly understood. These factors were explored as independent predictors of health care utilization.

METHODS

Baseline data from a prospective cohort study of childhood asthma severity were used. Subjects were recruited from seven New England hospitals. Home interviews collected data on monthly symptoms, health care visits, insurance status, as well as sociodemographics and asthma-related risk factors (n = 804). Characteristics of providers' practices, board certifications, and asthma specialty were obtained from Folio's Medical Dictionaries for Connecticut and Massachusetts.

RESULTS

After adjusting for frequency of asthma-related primary care visits, primary provider practice type, use of asthma specialist, age, gender, medication use, and symptomatology, Medicaid children still used the ED more frequently for asthma services than privately insured children (RR, 1.7; 95% CI, 1.1, 2.5). In general, race/ethnicity did not modify the relationship between insurance status and health care use, except that black children receiving Medicaid were 90% (95% CI, 0.0, 0.7) less likely to have had > or = 3 routine primary care visits for asthma in the previous year than black privately insured children. White children receiving Medicaid were 2.5 (95% CI, 1.0, 6.9) times more likely to use the ED for asthma than privately insured white children.

CONCLUSIONS

The results suggest that enabling, structural, and need factors do not necessarily explain observed differences in pediatric asthma health care use by insurance status. Future investigation must explore other explanatory factors such as maternal attitudes and beliefs and patient-provider communication.