Racial/ethnic differences in asthma-related emergency department visits and hospitalizations among children with wheeze in Buffalo, New York

Utilization of electronic portal referrals to a community agency for children presenting with an asthma exacerbation to a pediatric emergency department

PURPOSE

To evaluate referral rates and factors associated with referrals to a community agency for children evaluated for an asthma exacerbation at a pediatric emergency department (PED) and compare PED visits for asthma the following year between those referred and not referred.

METHODS

We reviewed electronic health records of children 2-18 years evaluated in our PED from 01/01/2019 to 12/31/2019 with an ICD-10 diagnostic code for asthma (J45x) following the introduction of a portal where clinicians could refer children to a community agency focused on improving health outcomes for asthma. We abstracted data on demographics, PED visits, and hospitalizations and used multivariate logistic regression to evaluate factors associated with referrals.

RESULTS

Of the 2262 charts analyzed, the majority of patients were male (61%), Black (76%), and held public insurance (71%). Only a minority of patients (n = 140, 6%) were referred. Age [6-12 years (AOR: 1.93, 95% CI: 1.21-3.08, p = .006), 13-18 years (AOR: 10.61, 95% CI: 6.53-17.24, p = .001)] and lifetime number of PED asthma visits [≥3 visits (AOR: 1.91, 95% CI, 1.01-3.62, p = .05)] were associated with referral. There was no significant difference in the mean number of PED visits in one year [referred: 0.59 (SD1.2) vs. not referred: 0.79 (SD1.3), t = 1.70, p = .09] between the two groups.

CONCLUSION

The referral rate to community agency from PED for asthma is low. There was no difference in short-term PED utilization for asthma between those referred and not referred.

California's early transition to electric vehicles: Observed health and air quality co-benefits

The transition to electric vehicles is projected to have considerable public health co-benefits, but most evidence regarding air quality and health impacts comes from projections rather than real-world data. We evaluated whether population-level respiratory health and air quality co-benefits were already detectable at the relatively low levels of zero-emissions vehicles (ZEVs: battery electric, plug-in hybrid, hydrogen fuel cell vehicle) adoption in California, and evaluated the ZEV adoption gap in underserved communities. We conducted a zip code-level ecologic study relating changes in annual number of ZEVs (nZEV) per 1000 population from 2013 to 2019 to: (i) annual average monitored nitrogen dioxide (NO2) concentrations and (ii) annual age-adjusted asthma-related emergency department (ED) visit rates, while considering educational attainment. The average nZEV increased from 1.4 per 1000 population in 2013 (standard deviation [SD]: 2.1) to 14.7 per 1000 in 2019 (SD: 14.7). ZEV adoption was considerably slower in zip codes with lower educational attainment (p < 0.0001). A within-zip code increase of 20 ZEVs per 1000 was associated with a - 0.41 ppb change in annual average NO2 (95 % confidence interval [CI]:-1.12, 0.29) in an adjusted model. A within-zip code increase of 20 ZEVs per 1000 population was associated with a 3.2 % decrease in annual age-adjusted rate of asthma-related ED visits (95 % CI:-5.4, -0.9). Findings were supported by a variety of sensitivity analyses. Observational data on the early phase ZEV transition in California provided a natural experiment, enabling us to document the first real-world associations between increasing nZEV and changes in air quality and health. Results suggest co-benefits of the early-phase transition to ZEVs but with an adoption gap among populations with lower socioeconomic status which threatens the equitable distribution of possible co-benefits.

Changes in the Use of Invasive and Noninvasive Mechanical Ventilation in Pediatric Asthma: 2009-2019

Rationale: Despite lower overall hospitalization rates for asthma in recent years, there has been an increase in the number of pediatric patients receiving intensive care management in the United States. Objectives: To investigate how the use of invasive and noninvasive mechanical ventilation for asthma has changed in the context of an evolving cohort of critically ill pediatric patients with asthma. Methods: We analyzed children admitted to intensive care units for asthma from 2009 through 2019 in the Virtual Pediatric Systems database. Regression analyses were used to evaluate how respiratory support interventions, mortality, and patient characteristics have changed over time. Odds ratios were calculated to determine how patient characteristics were associated with respiratory support needs. Stratified analyses were performed to determine how changing practice patterns may have differed between patient subgroups. Results: There were 67,614 admissions for 56,727 patients analyzed. Intubation occurred in 4.6% of admissions and decreased from 6.9% to 3.4% over time (P < 0.001), whereas noninvasive ventilation as the maximal respiratory support increased from 8.9% to 20.0% (P < 0.001). Over time, the cohort shifted to include more 2- to 6-year-olds and patients of Asian/Pacific Islander or Hispanic race/ethnicity. Although intubation decreased and noninvasive ventilation increased in all subgroups, the changes were most pronounced in the youngest patients and slightly less pronounced for obese patients. Conclusions: In pediatric asthma, use of intubation has halved, whereas use of noninvasive ventilation has more than doubled. This change in practice appears partially related to a younger patient cohort, although other factors merit exploration.

Effect of extreme temperatures on daily emergency room visits for mental disorders

Relatively few studies investigated the effects of extreme temperatures (both heat and cold) on mental health (ICD-9: 290-319; ICD-10: F00-F99) and the potential effect modifications by individuals' age, sex, and race. We aimed to explore the effect of extreme temperatures of both heat and cold on the emergency room (ER) visits for mental health disorders, and conducted a stratified analysis to identify possible susceptible population in Erie and Niagara counties, NY, USA. To assess the short-term impacts of daily maximum temperature on ER visits related to mental disorders (2009-2015), we applied a quasi-Poisson generalized linear model combined with a distributed lag non-linear model (DLNM). The model was adjusted for day of the week, precipitation, long-term time trend, and seasonality. We found that there were positive associations between short-term exposure to extreme ambient temperatures and increased ER visits for mental disorders, and the effects can vary by individual factors. We found heat effect (relative risk (RR) = 1.16; 95% confidence intervals (CI), 1.06-1.27) on exacerbated mental disorders became intense in the study region and subgroup of population (the elderly) being more susceptible to extreme heat than any other age group. For extreme cold, we found that there is a substantial delay effect of 14 days (RR = 1.25; 95% CI = 1.08-1.45), which is particularly burdensome to the age group of 50-64 years old and African-Americans. Our findings suggest that there is a positive association between short-term exposure to extreme ambient temperature (heat and cold) and increased ER visits for mental disorders, and the effects vary as a function of individual factors, such as age and race.

Combined Effect of Race/Ethnicity and Type of Insurance on Reuse of Urgent Hospital-Based Services in Children Discharged with Asthma

Asthma is a leading cause of health disparity in children. This study explores the joint effect of race/ethnicity and insurance type on risk for reuse of urgent services within a year of hospitalization. Data were collected from 604 children hospitalized with asthma between 2012 and 2015 and stratified with respect to combination of patients’ insurance status (public vs. private) and race/ethnicity (white vs. nonwhite). Highest rates for at least one emergency department (ED) revisit (49.5%, 95% CI 42.5, 56.5) and for average revisits (1.03, 95% CI 0.83, 1.22) were recorded in nonwhite children with public insurance. Adjusted models revealed higher chance for ED reuse in white as well as nonwhite children covered by public insurance. Hospitalization rate was not dependent on the combination of social determinants, but on the number of post-discharge ED revisits. The combined effect of race/ethnicity and health insurance are associated with post-discharge utilization of ED services, but not with hospital readmission.

Mapping inequality: Childhood asthma and environmental injustice, a case study of St. Louis, Missouri

As a geographic continuum of poverty and affluence has emerged, so too has a geographic continuum of good and poor health. Asthma is currently one of the most prevalent chronic childhood diseases. Over the past three decades, the greatest increases in asthma rates have been in urban areas and have disproportionately affected youth in poverty and those in racial and ethnic minority groups. Neighborhoods serve as a mechanism fostering environmental injustice and perpetuating these disparities in health outcomes and life opportunity for our most vulnerable populations. Using Geographic Information Systems (GIS) methods in a case study of St. Louis Missouri, this study examines local environmental risk by identifying 'hotspots,' or statistically significant spatial clustering of high or low levels of childhood asthma, and associations with neighborhood characteristics, socio-demographic characteristics, and access to healthcare resources within these hotspots. Results revealed statistically significant clustering of high asthma rates in areas with more non-White and poor residents, higher rates of public housing, deteriorating housing, and violent crime. High asthma hotspots were also located in areas with limited physical access to healthcare resources, such as physicians and medication, and lower school attendance rates. Residents of these high asthma hotspots experience greater environmental risk, and significant disparities in health and education outcomes, physical and financial healthcare resources, and overall well-being. This study demonstrates these place-based inequalities and presents clear evidence of environmental injustice, supporting the need for investments and interventions to improve the environments, health, and economic resources of our most vulnerable youth.

Moving toward consensus on diagnosis and management of severe asthma in children

Children with severe asthma continue to experience symptoms despite long-term treatment with high doses of corticosteroids. Moreover, the heterogeneous nature of asthma and the presence of several phenotypes have limited our ability to develop an optimized management strategy for these patients. Adequate management of severe asthma in children necessitates a detailed understanding of what makes asthma difficult to control, knowledge of the causal factors, review of diagnosis for accurate identification of pediatric patients with severe asthma and a precise definition of the phenotypes to be able to better target the therapy. Advancement in all these aspects is likely to improve childhood asthma treatment in the future. Although our understanding of severe pediatric asthma has grown in recent years, there remains a lack of consensus and clarity around critical aspects of this condition. This review attempts to present a harmonized view on the definition of severe asthma in the pediatric age group, identification of phenotypes and diagnosis, the inflammatory cascade, pharmacological and non-pharmacological treatment strategies, considerations for follow-up and referral to specialists, and disease prevention strategies.

Does receiving care in a medical home reduce racial/ethnic disparities in ED visits among children with asthma in the United States?

Evidence has shown the implementation of medical home model improves care quality and outcomes. However, it is not clear whether receiving care from a medical home has any impact on racial/ethnic disparities in emergency department (ED) use by children with asthma. This study using the US National Survey of Children with Special Health Care Needs, 2009-2010, estimated racial/ethnic disparities in ED use. Generalized liner models were used to examine factors associated with ED use. Racial/ethnic differences in ED use were attenuated after adjusting for socio-economic variables. Ratios of prevalence ratios were calculated to examine the effect modification of medical home on ED use associated with race/ethnicity. The adjusted prevalence ratio of ED use of the Black to non-Hispanic White was 1.51 (95% confidence interval (CI): 1.36-1.67) with medical home and 1.35 (95% CI: 1.24-1.47) without medical home. Among those with care from a medical home Latino children had higher ED use compared with White children. There is no evidence that the self-reported care from a medical home narrows the gaps in ED use between non-Hispanic White and Black or Latino children with asthma.

Factors associated with increased healthcare utilization among adults with asthma

OBJECTIVE

To evaluate determinants of increased emergency room (ER) visit and hospitalization among adults with asthma, with emphasis on the role of psychological distress, self-efficacy, and obesity.

METHODS

For analysis 2009, 2011/2012 California Health Interview Survey was used. Adults who reported lifetime asthma were selected. Association between ER and overnight hospital stay with population characteristics were conducted using chi-square analysis. Multivariable binary logistic regression models, taking into account control variables, were utilized to assess the relationship between ER visit or overnight hospital stay with that of psychological distress, self-efficacy, and obesity.

RESULTS

Odds of ER visits were higher among those with mild-to-moderate psychological distress (adjusted odds ratio [aOR] = 1.94, 95% CI: 1.28, 2.94), and among those with serious psychological distress (aOR = 2.62, 95% CI: 1.65, 4.16). Mild-to-moderate distress was associated with two-fold increase in hospital overnight stay (aOR = 2.05, 95% CI: 1.29, 3.25). Adults with asthma who reported low self-efficacy had increased ER visits (aOR = 6.21, 95% CI: 3.63, 10.65) and hospitalization (aOR = 4.13, 95% CI: 2.63, 6.49). Finally, adults who had asthma and were obese had higher odds of ER visits (aOR = 1.60, 95% CI: 1.20, 2.13).

CONCLUSIONS

Healthcare utilization is higher among asthma patients with psychological distress, low self-efficacy, and obesity. Interventions, such as incorporation of integrated care models, are critical to ensure early screening of mental health status among such patients. In addition, there is a need for patient education and improved weight management among adults with asthma.

Disparities in Mortality and Morbidity in Pediatric Asthma Hospitalizations, 2007 to 2011

OBJECTIVE

Asthma is a leading cause of pediatric admissions. Although several factors including race have been linked to increased overall asthma morbidity and mortality, few studies have explored factors associated with inpatient asthma outcomes. We examined factors associated with mortality and morbidity in children admitted for asthma.

METHODS

Data were obtained from the US Nationwide Inpatient Sample for 2007 to 2011. Patients 2 to 18 years old with a primary diagnosis of asthma were included. Predictor variables were sociodemographic and hospital factors and acute/chronic secondary diagnoses. Outcomes were mortality, intubation, length of stay (LOS), and costs. Weighted national estimates were calculated. Multivariable analyses were performed.

RESULTS

There were 97,379 (478,546 weighted) asthma admissions. Most patients were male (60.6%); 30% were white, 28% black, and 18% Hispanic. Mortality rate was 0.03%, and 0.3% were intubated. Median LOS was 2 (interquartile range, 1-3) days. Median costs were $2,950 (interquartile range, $1990-$4610). Native American race, older age (13-18 years), and West region were significant independent predictors of mortality. Intubation rate was lower in Hispanic compared with white children (P = .028). LOS was shorter in Asian compared with white children (P = .022) but longer in children with public insurance and from low income areas (P < .001). Average costs were higher in black, Hispanic, and Asian compared with white children (P < .05).

CONCLUSIONS

With the exception of Native Americans, race/ethnicity is not associated with inpatient asthma mortality and has varied effects on morbidity. Recognition of factors associated with increased asthma mortality and morbidity might allow for earlier, more effective treatment and avoidance of complications.

Assessing disparities in the receipt of inhaled corticosteroid prescriptions for asthma by Hispanic and non-Hispanic white patients

RATIONALE

Inhaled corticosteroids (ICS) are widely used in the management of asthma. Prior research suggests that access to ICS among patients with asthma may vary by ethnicity.

OBJECTIVES

Study objectives were to determine if there is a difference in the proportion of Hispanic and non-Hispanic white patients with asthma in the receipt of an ICS prescription and to determine independent predictors for the receipt of an ICS prescription for asthma.

METHODS

The 2009 U.S. Medical Expenditure Panel Survey data were used to compare the receipt of ICS prescription among patients with asthma with the following inclusion criteria: Hispanic and non-Hispanic white ethnicity, age over 4 years, and diagnostic codes for asthma. Multiple logistic regression was used to determine the influence of race/ethnicity and other significant factors on the receipt of an ICS prescription.

MEASUREMENTS AND MAIN RESULTS

There were 1,469 patients with asthma, corresponding to a weighted sample of 14,401,069 U.S. patients with asthma who met the inclusion criteria, represented by 16.1% Hispanic, 59.5% female, and mean age of 39.9 years. Among non-Hispanic white patients with asthma, 39.7% (35% children and 41% adults) had a receipt of an ICS prescription compared with 22.2% of Hispanic patients (23.9% children and 21.2% adults); P < 0.001. In the multiple regression model, Hispanic patients aged 18 years or older had 43% lower odds (odds ratio, 0.6; 95% confidence interval, 0.3-0.9) of having a receipt of an ICS prescription compared with non-Hispanic white patients, independent of other factors. There was no significant difference in receipt of an ICS prescription between Hispanic and non-Hispanic white children with asthma (aged 4-17 yr).

CONCLUSIONS

The disparity in the receipt of ICS prescription between Hispanic and non-Hispanic white adult patients with asthma could result in suboptimal asthma management, a higher rate of exacerbations, and higher health care costs in this growing minority population. The differences and potential disparities in the receipt of an ICS prescription between Hispanic and non-Hispanic white patients with asthma warrant further investigation to better understand the reasons for such disparities, along with their impact on the U.S. health care burden and interventions that can be undertaken to reduce these disparities.

Causes, costs, and risk factors for unplanned return visits after adenotonsillectomy in children

OBJECTIVE

To review the causes, costs, and risk factors for unplanned return visits and readmissions after pediatric adenotonsillectomy (T&A).

METHODS

Review of administrative database of outpatient adenotonsillectomy performed at any facility within a vertically integrated health care system in the Intermountain West on children age 1-18 years old between 1998 and 2012. Data reviewed included demographic variables, diagnosis associated with return visit and costs associated with return visits.

RESULTS

Data from 39,906 children aged 1-18 years old were reviewed. A total of 2499 (6.3%) children had unplanned return visits. The most common reasons for return visits were bleeding (2.3%), dehydration, (2.3%) and throat pain (1.2%). After multivariate analysis, the main risk factors for any type of return visits were Medicaid insurance (OR=1.64 95% CI 1.47-1.84), Hispanic race (OR=1.36 95% CI 1.13-1.64), and increased severity of illness (SOI) (OR=11.29 95% CI 2.69-47.4 for SOI=3). The only factor associated with increased odds of requiring an inpatient admission on return visit was length of time spent in PACU (p<0.001). A linear relationship was also observed between the child's age and the risk of post-tonsillectomy hemorrhage.

CONCLUSION

Children with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity should be targeted with increased education and interventions in order to reduce unplanned visits after T&A. Further studies on post-tonsillectomy complications should include evaluating the effect of surgical technique and post-operative pain management on all complications and not solely post-tonsillectomy hemorrhage.

Poor asthma education and medication compliance are associated with increased emergency department visits by asthmatic children

BACKGROUND:

Acute exacerbations of bronchial asthma remain a major cause of frequent Emergency Department (ED) visits by pediatric patients. However, other factors including psychosocial, behavioural and educational, are also reportedly associated with repetitive ED visits. Therefore, it is necessary to determine whether such visits are justifiable.

OBJECTIVE:

The objective of this cross-sectional study was to identify risk factors associated with visits to ED by asthmatic children.

METHODS:

Asthmatic children (n = 297) between 1-17 years old were recruited and information collected at the time of visiting an ED facility at two major hospitals.

RESULTS:

Asthmatic patients visited the ED 3.9 ΁ 3.2 times-per-year, on average. Inadequately controlled asthma was perceived in 60.3% of patients. The majority of patients (56.4%) reported not receiving education about asthma. Patients reflected misconceptions about the ED department, including the belief that more effective treatments are available (40.9%), or that the ED staff is better qualified (27.8%). About half of patients (48.2%) visited the ED because of the convenience of being open 24 hours, or because they are received immediately (38.4%). Uncontrolled asthma was associated with poor education about asthma and/or medication use. Patients educated about asthma, were less likely to stop corticosteroid therapy when their symptoms get better (OR:0.55; 95% CI:0.3-0.9; P = 0.04).

CONCLUSION:

This study reports that most patients had poor knowledge about asthma and were using medications improperly, thus suggesting inefficient application of management action plan. Unnecessary and frequent visits to the ED for asthma care was associated with poor education about asthma and medication use. Potential deficiencies of the health system at directing patients to the proper medical facility were uncovered and underline the necessity to improve education about the disease and medication compliance of patients and their parents/guardians.

Pediatric asthma readmission: asthma knowledge is not enough?

OBJECTIVE

To characterize factors associated with readmission for acute asthma exacerbation, particularly around caregiver asthma knowledge, beliefs, and reported adherence to prescribed medication regimens.

STUDY DESIGN

We enrolled 601 children (aged 1-16 years) who had been hospitalized for asthma. Caregivers completed a face-to-face survey regarding their asthma knowledge, beliefs, and medication adherence. Caregivers also reported demographic data, child's asthma severity, exposure to triggers, access to primary care, and financial strains. We prospectively identified asthma readmission events via billing data over a 1-year minimum follow-up period. We examined time to readmission with Cox proportional hazards.

RESULTS

The study cohort's median age was 5 years, 53% were African American, and 57% were covered by Medicaid. At 1 year, 22% had been readmitted for asthma. In the multivariate analysis, a caregiver's demonstration of increased asthma knowledge was associated with increased readmission risk. In addition, children whose caregivers reported less-than-perfect adherence to daily medication regimens had increased readmission risk. Likewise, having previously been admitted for asthma, decreased medical home access, and black race were associated with increased readmission risk.

CONCLUSION

In a multifactorial assessment of risk factors for asthma readmission, greater asthma knowledge and decreased medication adherence were associated with readmission. Inpatient efforts to prevent readmission might best target medication adherence rather than continuing to primarily provide asthma education.

Examining household asthma management behavior through a microeconomic framework

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

Emergency department charges for asthma-related outpatient visits by insurance status

Though Americans make 1.8 million asthma-related outpatient visits to the emergency department (ED) annually, little is known about the episodic charges for asthma care in the ED. We therefore sought to assess the bills patients could face for acute asthma incidents by examining hospital charges for asthma-related outpatient ED visits. We performed a nationwide, cross-sectional study of 2.9 million weighted asthma-related outpatient ED visits from 2006-2008 using data from the Medical Expenditure Panel Survey. We found that the average charge for an outpatient ED visit was $1,502 (95% CI $1,493-$1,511). The charges did not vary significantly by insurance group but did increase significantly with age. Our results indicate that the financial burden of ED care for asthma may take a severe toll on low-income populations who have limited ability to pay, especially patients who must pay undiscounted charges, including the uninsured and those on high-deductible health plans.

Racial/ethnic differences in hospital use and cost among a statewide population of children with Down syndrome

Children with Down syndrome (DS) use hospital services more often than children without DS, but data on racial/ethnic variations are limited. This study generated population-based estimates of hospital use and cost to 3 years of age by race/ethnicity among children with DS in Massachusetts using birth certificates linked to birth defects registry and hospital discharge data from 1999 to 2004. Hospital use (≥ 1 post-birth hospitalization and median days hospitalized birth and post-birth) and reasons for hospitalization were compared across maternal race/ethnicity using relative risk (RR) and Wilcoxon rank sums tests, as appropriate. Costs were calculated in 2011 United States dollars. Greater hospital use was observed among children with DS with Hispanic vs. Non-Hispanic White (NHW) mothers (post-birth hospitalization: RR 1.4; median days hospitalized: 20.0 vs. 11.0, respectively). Children with DS and congenital heart defects of Non-Hispanic Black (NHB) mothers had significantly greater median days hospitalized than their NHW counterparts (24.0 vs. 16.0, respectively). Respiratory diagnoses were listed more often among children with Hispanic vs. NHW mothers (50.0% vs. 29.1%, respectively), and NHBs had more cardiac diagnoses (34.1% vs. 21.5%, respectively). The mean total hospital cost was nine times higher among children with DS ($40,075) than among children without DS ($4053), and total costs attributable to DS were almost $18 million. Median costs were $22,781 for Hispanics, $18,495 for NHBs, and $13,947 for NHWs. Public health interventions should address the higher rates of hospital use and hospitalizations for respiratory and cardiac diseases among racial/ethnic minority children with DS in Massachusetts.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative

OBJECTIVES

We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control.

METHODS

Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model.

RESULTS

In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use.

CONCLUSIONS

Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

The challenge of asthma in minority populations

The burden and disparity of asthma in race/ethnic minorities present a significant challenge. In this review, we will evaluate data on asthma epidemiology in minorities, examine potential reasons for asthma disparities, and discuss strategies of intervention and culturally sensitive care.

Puerto Rican families' experiences of asthma and use of the emergency department for asthma care

Puerto Ricans have been found to have higher asthma prevalence rates than non-Hispanic whites, blacks, and all other Hispanic subgroups. They also have the highest rates of emergency department (ED) use for the management of their asthma. Using a hermeneutic phenomenological approach, the aim of this study was to describe the lived experience of Puerto Rican families caring for their child's asthma and using the ED for asthma care. Six themes were generated from in-depth interviews with 10 Puerto-Rican caregivers: (1) The Folklore of Asthma, (2) Culture and the Medicine Woman, (3) In Awe of Asthma, (4) Praying to God, (5) The Decision-Time to Go, and (6) The ED Environment. The findings emphasize the necessity of establishing and maintaining a therapeutic partnership between primary care providers and families of children with asthma. The results may be used as a foundation for understanding motivations for seeking asthma care in the ED.

Racial and ethnic differences in the management of childhood asthma in the United States

OBJECTIVES

We examined racial and ethnic differences in the management of childhood asthma in the United States and the extent that care conformed to clinical best practices.

METHODS

Two years of pooled data from the National Health Interview Survey were analyzed using logistic regression. The sample included all children between ages 2 and 17 years who had asthma currently and had been diagnosed with asthma by a doctor or health professional (n = 1757; 465 African-American, 212 Mexican-American, 190 Puerto Rican and other Hispanic, 806 white, non-Hispanic, and 84 children of other and multiple races and ethnicities).

RESULTS

African-American children with asthma were significantly less likely than white, non-Hispanic children to have taken preventive asthma medication, but more likely to have had an asthma management plan. Mexican-American and Puerto Rican and other Hispanic children did not differ significantly from white, non-Hispanic children in either receiving preventive asthma medication or having an asthma management plan. Caregivers of African-American and Puerto Rican and other Hispanic children were more likely to report that they or their child had taken a course or class on how to manage their child's asthma. We did not find racial or ethnic differences in the extent children used quick-relief asthma medication or received advice about reducing asthma triggers in their home, school, or work environments.

CONCLUSIONS

This work highlights a need for more research on racial and ethnic differences in asthma management. Implications for public health responses and racial and ethnic disparities in asthma morbidity are discussed.

Factors associated with rehospitalizations of very low birthweight infants: impact of a transition home support and education program

OBJECTIVE

To determine the effects of a transition-home education and support program, BPD, and health insurance type on VLBW infant rehospitalizations at 3 and 7 months corrected age. It was hypothesized that the transition-home program would be associated with decreased rehospitalizations between Phase 1 and 2, and public health insurance and BPD would be associated with increased rehospitalizations.

METHODS

274 infants with birth weight <1500 g were enrolled in two successive years of a transition-home program (Phase 1-start-up) and (Phase 2-full implementation) and followed to 7 months CA.

RESULTS

The Phase 2 rehospitalization rates were lower but not statistically significant at both 3 months (20% and 15%; p=0.246), and 7 months (24% and 17%; p=0.171). Infants with public insurance had twice as many rehospitalizations by 3 months (28% versus 11%; p=0.018) in Phase 1. In regression analyses the intervention effects did not achieve significance for the cohort at 3 months (OR=0.63; CI=0.33 to 1.20) or 7 months (OR=0.61; CI=0.33 to 1.13). BPD and public insurance did not reach significance in the models whereas siblings were significantly associated with increased odds of rehospitalization. In subgroup analyses for infants on pubic health insurance the intervention significantly decreased the odds of rehospitalization between Phase 1 and 2(OR=0.43; CI=0.19 to 0.96) at 3 months.

CONCLUSIONS

Our findings suggest that a transition-home program may be beneficial to reduce the rehospitalization rate for VLBW infants, and infants on public insurance may derive greater benefit.

Childhood asthma and indoor allergen exposure and sensitization in Buffalo, New York

This nested case-control study examined the association between prevalent asthma and indoor allergen sensitization and/or exposure among children (aged 5-17 years) in Buffalo, New York. The study included a self-administered questionnaire, clinical interviews, skin allergen sensitivity tests and home dust sampling for house dust mites, cat, dog, cockroach and mouse allergens. After adjusting for multiple confounders, asthma cases had higher odds of being sensitized to Der p dust mites (odds ratio [OR]=1.94, 95% confidence interval (CI): 1.13-3.35), cat (OR=1.96, 95% CI: 1.13-3.39), or dog allergens (OR=1.89, 95% CI: 1.10-3.22) than the controls. A significantly positive association between asthma status presence of cat allergen in the child's mattress (ORs: 2.61, 95% CI: 1.09-6.28) was also found. Children with both sensitization and environmental exposure to cat allergens had higher odds of asthma (OR=7.08, 95% CI: 2.12-23.62) than those who were only sensitized to cat allergen (OR=2.31, 95% CI: 1.01-5.32) or had only home exposures (OR=1.47, 95% CI: 0.47-4.65). The association between allergen sensitization and asthma was more consistent than for home exposures. The findings help to confirm the role of allergen sensitization and home exposure in regard to asthma, and suggest that both, individually and jointly, are associated with asthma.

Using electronic health records to drive discovery in disease genomics

If genomic studies are to be a clinically relevant and timely reflection of the relationship between genetics and health status--whether for common or rare variants--cost-effective ways must be found to measure both the genetic variation and the phenotypic characteristics of large populations, including the comprehensive and up-to-date record of their medical treatment. The adoption of electronic health records, used by clinicians to document clinical care, is becoming widespread and recent studies demonstrate that they can be effectively employed for genetic studies using the informational and biological 'by-products' of health-care delivery while maintaining patient privacy.

Exploring modifiable risk factors for wheezing in African American premature infants

OBJECTIVE

To examine the degree to which obesity during infancy, consistent exposure to secondhand smoke, and parenting (positive attention, maternal involvement, and negative control) were related to early development of wheezing in a cohort of African American premature infants at 2, 6, 12, 18, and 24 months corrected age.

DESIGN

Secondary analysis of a subset of variables from a larger nursing support intervention study.

SETTING

Two regional perinatal centers in the southeastern United States.

PARTICIPANTS

One hundred and sixty-eight African American premature infants (70 boys, 98 girls) who weighed less than 1,750 g or required mechanical ventilation and their mothers.

METHODS

The presence of wheezing was obtained from maternal report at 2, 6, 12, 18, and 24 months. Infants were considered to have medically significant wheezing if they were using bronchodilators or pulmonary anti-inflammatory medications.

RESULTS

The percentage of infants who had medically significant wheezing increased from 12% at 2 months to 24% at 24 months corrected age. Infants who received more positive attention from their mothers had a slightly higher increase in the probability of developing wheezing over time. Infants of mothers who received public assistance had an increased probability of wheezing. Consistent exposure to secondhand smoke, obesity during infancy, maternal negative control, and maternal involvement were not related to the development of wheezing.

CONCLUSION

These findings suggest that the likelihood of developing wheezing in African American premature infants is associated with receiving more positive attention from their mothers and having mothers who receive public assistance. Because modifiable risk factors were not highly related to wheezing, intervention efforts need to focus on early identification and treatment of wheezing and asthma-related symptoms.

Association between indoor mold and asthma among children in Buffalo, New York

Asthma is a leading chronic disease among children and places a significant burden on public health. Exposure to indoor mold has been associated with asthma symptoms. However, many mold assessments have relied on visual or other identification of damp conditions and mold presence, thus have not examined associations with specific fungal genera. The objective of this case-control study was to examine the relationship between airborne mold concentrations and asthma status among children and to identify the contribution from specific mold genera in air. Participants completed a questionnaire of home environmental conditions and underwent indoor air sampling in the home, from which viable and total-count fungal spores were quantified. The most prevalent fungi in the homes were the allergenic molds Cladosporium (98% and 87% of homes from viable and total count samples, respectively) and Penicillium (91% and 73%). There were no significant differences in mean fungal concentrations between the homes of cases and controls, although the observed rate of exposure to several molds was higher among the cases. Among children who lacked a family history of asthma, cases had significantly higher exposures to viable Aspergillus. Measured humidity levels in the home corresponded with some self-reported indicators of mold and dampness.

PRACTICAL IMPLICATIONS

The results of this study support existing literature that indoor fungal exposures play a role in current asthma status and that some qualitative assessments of mold exposure correspond to fungi present in indoor air.

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.

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

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

Insurance status and the variable management of children presenting to the emergency department with bronchiolitis

OBJECTIVE

To determine if insurance type is associated with differences in the management of children presenting to the emergency department (ED) with bronchiolitis

METHODS

We analyzed data from a 30-center, prospective cohort study of children younger than 2 years with bronchiolitis presenting to the ED. Insurance status was defined as private, public, and no insurance.

RESULTS

Of 1450 patients, 473 (33%) had private, 928 (64%) had public, and 49 (3%) had no insurance. Multivariable analysis found that children with public insurance were less likely to receive inhaled β-agonists (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.50-0.92) or antibiotics (OR, 0.61; 95% CI, 0.42-0.89) the week before the ED visit. Children without insurance were less likely to have a primary care provider (OR, 0.15; 95% CI, 0.04-0.57) or receive laboratory testing in the ED (OR, 0.41; 95% CI, 0.19-0.88). The children's clinical presentation (eg, respiratory rate, oxygen saturation, and retractions) and ED treatments (eg, inhaled β-agonists, inhaled racemic epinephrine, systemic corticosteroids, and antibiotics) were similar. Likewise, hospital admission (multivariable OR 1.04; 95% CI, 0.45-2.42) was similar between insurance groups.

CONCLUSIONS

We noted some pre-ED and ED management differences across insurance types for children presenting to the ED with bronchiolitis. Although these variations may reflect treatments with unproven benefits, all children regardless of insurance should receive similar care. Despite these management variations, there were no differences in medications delivered in the ED or admission rate.

Uncontrolled asthma in a commercially insured population from 2002 to 2007: trends, predictors, and costs

OBJECTIVE

Uncontrolled asthma leads to preventable morbidity and increased health care utilization. The authors examined trends, predictors, and costs of uncontrolled asthma over 5 years in a large health plan population.

METHODS

The authors retrospectively examined administrative health claims data from mid-2000 to mid-2007 on patients with asthma aged 1 to 56 years (n = 54,653 patient-years, 28,595 unique patients). Uncontrolled asthma events were defined as > or =2 oral steroid fills or > or =5 short-acting beta(2)-agonist (SABA) fills over 12 months, or an asthma-related hospitalization or emergency department (ED) visit. Multivariate generalized mixed regression models determined patient- and neighborhood-level predictors for uncontrolled asthma events. The authors compared asthma-related costs for patients with and without uncontrolled asthma events.

RESULTS

In 2002-2003, 39% of patients had > or =1 uncontrolled asthma event. Most frequent were high use of rescue asthma medications. Asthma-related hospitalizations and ED visits were infrequent. The percentage having uncontrolled asthma events decreased significantly over time to 27% in 2006-2007, due to a decreased rate of frequent SABA fills. Males and adults > or =24 years had higher odds of medication-based uncontrolled asthma events, whereas residence in neighborhoods with more minorities and lower educational attainment was associated with ED visits or hospitalizations. Patients with uncontrolled asthma events had significantly higher asthma-related costs.

CONCLUSIONS

In this population, the proportion of patients with uncontrolled asthma, particularly as indicated by high SABA fills, decreased over a 5-year period. Several individual- and neighborhood-level characteristics were associated with uncontrolled asthma events. Clinicians and health plans can identify higher-risk patients in order to target asthma management strategies and reduce asthma-related morbidity and its associated costs.

The impact of race and ethnicity on care in the pediatric emergency department

PURPOSE OF REVIEW

To review healthcare disparities encountered by pediatric patients in the emergency department. The discussion focuses on recent research that is relevant to the field of pediatric emergency medicine.

RECENT FINDINGS

The majority of recent research focuses on healthcare disparities affecting black and Hispanic children and adolescents. Disparities are identified in the areas of emergency department utilization, the provision of effective interpreter services, and the epidemiology and management of specific illnesses, including asthma, adolescent sexual health, and mental health. The findings suggest that disparities persist after controlling for socioeconomic factors and that the effect on healthcare outcomes is measurable. Interventions to mitigate healthcare disparities have shown mixed results. There is some evidence that disparity reduction is possible.

SUMMARY

Recent research demonstrates that healthcare disparities exist in several areas affecting the delivery of quality pediatric emergency care. These disparities are shaped by a complex interaction of social, cultural, behavioral, educational, and financial factors. More research is needed to increase the body of knowledge as to why disparities exist. The success of this future research may require an interdisciplinary approach incorporating experts from multiple scientific fields.

A current picture of asthma diagnosis, severity, and control in a low-income minority preteen population

BACKGROUND

Asthma severity, control, type of medical regimen provided, and compliance with it are not well understood in minority patients at the transition stage from childhood to adolescence.

OBJECTIVE

Describe the level of asthma severity and control and the clinical regimens provided to a large population of low-income, African American children at this developmentally significant period.

METHODS

Parents of 1292 children with asthma among 6827 preteens in 19 middle schools in predominantly African American (94%), low-income neighborhoods in Detroit, Michigan, were enrolled in the study. Data were collected through self-administered survey and telephone interviews and were useable for 936 participants. Study queries related to demographics, asthma symptoms, and medication use. Mixed effects models with a random intercept for school were used to determine severity and control and the association of medical regimens to these.

RESULTS

Sixty-seven percent of children with probable asthma had received a physician's diagnosis. Being female was associated with being undiagnosed (p = .02). Forty-seven with no diagnosis had persistent asthma and 10% of these were classified as severe. Sixty-eight percent with a diagnosis and asthma medicine prescriptions were not controlled. Compliant use of controller medicine was associated with poorer asthma control compared to noncompliant controller users (p = .04) and reliever-only users (p < .001). Thirty-nine percent of children had controller medicine; of those 40% were not compliant with controller use; 9% nebulized their controller medicine.

CONCLUSIONS

Care provided low-income minority children at an important stage in their development was not consistent with guidelines for asthma control. Therapy choices for treatment did not account for the actual level of their symptoms. Lack of an asthma diagnosis was significant in the population. Adolescent girls were at risk for not receiving a diagnosis. Patient compliance with asthma regimens was limited. Both clinician and patient education regarding effective asthma management appears needed regarding preteens in low-income minority communities.