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Qin X, Pate CA, Zahran HS. Factors associated with emergency department visits for asthma resulting in hospital admission-United States, 2020. J Asthma 2024; 61:717-724. [PMID: 38193801 PMCID: PMC11166518 DOI: 10.1080/02770903.2024.2303753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/07/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To identify risk factors associated with hospital admission following an ED visit for asthma at the time of discharge among U.S. children and adults. METHODS Asthma emergency department visits resulting in hospital admissions using discharge data among children (aged 0-17 years) and adults (aged 18 years or older) from the 2020 Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality were examined. Risk factors associated with hospital admission following ED visits were identified using univariable and multi-variable logistic regression models. RESULTS Among children, hospital admission after asthma-related ED visits was higher for females, ages less than 12 years, and discharged in January-March or in October-December and lower for Black children, Hispanic children, Medicaid or Medicare beneficiaries, other/no charge/self-pay, and in metropolitan non-teaching or non-metropolitan hospitals. Among adults, asthma ED visits resulting in hospital admissions were higher for females, ages 35 years or older, discharged in January-March, and for Medicare beneficiaries and lower for Black adults, Hispanic adults, adults of other races, other/no charge/self-pay, in metropolitan non-teaching or non-metropolitan hospitals, and median household income quartiles for patient's ZIP Code of less than $59,000 were lower. CONCLUSIONS Sociodemographic factors, healthcare use, and household income were significantly associated with hospital admissions at the time of discharge from the ED. Examining hospital admission after an ED visit for asthma is important in identifying these groups and better addressing their healthcare needs.
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Affiliation(s)
- Xiaoting Qin
- Asthma and Air Quality Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cynthia A. Pate
- Asthma and Air Quality Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hatice S. Zahran
- Asthma and Air Quality Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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2
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Haji T, Lyzwinski L, Dhaliwal C, Leung G, Giangioppo S, Radhakrishnan D. A real-world evaluation of the effectiveness and Sufficiency of Current Emergency Department Preventative Strategies for Reducing Emergency Department revisits in a Canadian children's hospital: a retrospective cohort study. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:37. [PMID: 38918807 PMCID: PMC11197375 DOI: 10.1186/s13223-024-00900-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/21/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Despite asthma guidelines' recommended emergency department preventative strategies (EDPS), repeat asthma-related emergency department (ED) visits remain frequent. METHODS We performed a retrospective cohort study of children aged 1-17 years presenting with asthma to the Children's Hospital of Eastern Ontario (CHEO) ED between September 1, 2014 - August 31, 2015. EDPS was defined as provision of education on trigger avoidance and medication technique plus documentation of an asthma action plan, a prescription for an inhaled controller medication or referral to a specialist. Logistic regression was used to identify factors associated with receipt of EDPS. We further compared the odds of repeat presentation to the ED within the following year among children who had received EDPS versus those who had not. RESULTS 1301 patients were included, and the mean age of those who received EDPS was 5.0 years (SD = 3.7). Those with a moderate (OR = 3.67, 95% CI: 2.49, 5.52) to severe (OR = 3.69, 95% CI: 2.50, 5.45) asthma presentation were most likely to receive EDPS. Receiving EDPS did not significantly reduce the adjusted odds of repeat ED visits, (OR = 0.82, 95% CI: 0.56, 1.18, p = 0.28). CONCLUSIONS Patients with higher severity asthma presentations to the ED were more likely to receive EDPS, but this did not appear to significantly decrease the proportion with a repeat asthma ED visit. These findings suggest that receipt of EDPS in the ED may not be sufficient to prevent repeat asthma ED visits in all children.
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Affiliation(s)
- Tahereh Haji
- Children's Hospital of Eastern Ontario, Ontario, Canada
| | | | - Cara Dhaliwal
- Children's Hospital of Eastern Ontario, Ontario, Canada
| | - Garvin Leung
- Children's Hospital of Eastern Ontario, Ontario, Canada
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3
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Aggarwal S, Cepalo T, Gill S, Thipse M, Clifton KL, Higginson A, Vu J, Bijelić V, Barrowman N, Giangioppo S, Radhakrishnan D. Factors associated with future hospitalization among children with asthma: a systematic review. J Asthma 2023; 60:425-445. [PMID: 35522051 DOI: 10.1080/02770903.2022.2070762] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Asthma is a leading cause of emergency department (ED) visits and hospitalizations in children, though many could be prevented. Our study objective was to identify factors from the published literature that are associated with future hospitalization for asthma beyond 30 days following an initial asthma ED visit. DATA SOURCES We searched CINAHL, CENTRAL, MEDLINE, and Embase for all studies examining factors associated with asthma-related hospitalization in children from January 1, 1992 to February 7, 2022.Selecting Studies: All citations were reviewed independently by two reviewers and studies meeting inclusion criteria were assessed for risk of bias. Data on all reported variables were extracted from full text and categorized according to identified themes. Where possible, data were pooled for meta-analysis using random effects models. RESULTS Of 2262 studies, 68 met inclusion criteria. We identified 28 risk factors and categorized these into six themes. Factors independently associated with future hospitalization in meta-analysis include: exposure to environmental tobacco smoke (OR = 1.94 95%CI 0.67-5.61), pets exposure (OR = 1.67 95%CI 1.17-2.37), and previous asthma hospitalizations (OR = 3.47 95% CI 2.95-4.07). Additional related factors included previous acute care visits, comorbid health conditions (including atopy), allergen exposure, severe-persistent asthma phenotype, inhaled steroid use prior to ED visit, poor asthma control, higher severity symptoms at ED presentation, warmer season at admission, longer length of stay or ICU admission, and African-American race/ethnicity. CONCLUSIONS We identified multiple factors that are consistently associated with future asthma hospitalization in children and could be used to identify those who would benefit from targeted preventative interventions.
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Affiliation(s)
| | - Tanita Cepalo
- Faculty of Science, Carleton University, Ottawa, Canada
| | - Sana Gill
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Madhura Thipse
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Kerry-Lee Clifton
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | | | - James Vu
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Vid Bijelić
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Sandra Giangioppo
- University of Toronto, Toronto, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Dhenuka Radhakrishnan
- Children's Hospital of Eastern Ontario, Ottawa, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Canada.,ICES, Ottawa, ON, Canada
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Qi Y, Shi P, Chen R, Zhou Y, Liu L, Hong J, Cao L, Lu Y, Dong X, Li J, Shi Y, Xia M, Ding B, Qian L, Wang L, Zhou W, Gui Y, Zhang X. Characteristics of childhood allergic diseases in outpatient and emergency departments in Shanghai, China, 2016-2018: a multicenter, retrospective study. BMC Pediatr 2021; 21:409. [PMID: 34535106 PMCID: PMC8447671 DOI: 10.1186/s12887-021-02880-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 08/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background The prevalence of allergic diseases (ADs), such as asthma and allergic rhinitis (AR), is increasing worldwide in both adults and children. Although ADs are common and frequently coexist in outpatient care, city-level data regarding the characteristics of childhood AD remain limited in China. This study aimed to assess the profile and characteristics of ADs in the city of Shanghai. Methods A multicenter retrospective study was designed to collect routine administrative data from outpatient and emergency departments from 66 hospitals in Shanghai, China, from 2016 to 2018. Children with asthma, AR, allergic conjunctivitis (AC), and allergic skin diseases were investigated. Demographic characteristics, patients visit pattern, spectrum of diagnosis, and comorbidities were analyzed. Results A total of 2,376,150 outpatient and emergency visits for ADs were included in the period from 2016 to 2018. Allergic skin diseases accounted for 38.9%, followed by asthma (34.8%), AR (22.9%), and AC (3.3%), with a male predominance in all four diseases. Asthma and allergic skin diseases were most frequent in the 1 to < 4 years of age group, while AR and AC were more common in the 4 to < 7 years of age group. Asthma accounted for the greatest number of annual and emergency visits. The most frequent comorbidity of asthma was lower respiratory tract infection (LRTI) (49.3%), followed by AR (20.5%) and upper respiratory tract infection (14.1%). The most common comorbidities of AR were otitis media (23.4%), adenoid hypertrophy/obstructive sleep apnea (22.1%), followed by LRTI (12.1%), asthma (9.4%) and chronic pharyngitis (8.9%). Conclusions Asthma and allergic skin diseases were the most common ADs in outpatient and emergency departments in the study period. Respiratory tract infection was the most common comorbidity of asthma in children. More attention should be devoted to the treatment of comorbidities to improve childhood AD outcomes with a better understanding of the characteristics of ADs in outpatient care. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02880-0.
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Affiliation(s)
- Yuanyuan Qi
- Department of Respiratory Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Peng Shi
- Department of Data Management and Statistics, Children's Hospital of Fudan University, Shanghai, China
| | - Renjie Chen
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education and NHC Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, 200032, China
| | - Yufeng Zhou
- Institute of Pediatrics, Children's Hospital of Fudan University, Shanghai, 201102, China.,Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China
| | - Lijuan Liu
- Department of Respiratory Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Jianguo Hong
- Department of Pediatrics, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, 200080, China
| | - Lanfang Cao
- Department of Pediatrics, Renji Hospital, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Yanming Lu
- Department of Pediatrics, South Campus, Renji Hospital, Shanghai Jiao Tong University, Shanghai, 201112, China
| | - Xiaoyan Dong
- Department of Respiratory Medicine, Children's Hospital of Shanghai Jiaotong University, Shanghai, 200040, China
| | - Jing Li
- Big Data Product Department, Wonders Information Co. Ltd., Shanghai, China
| | - Yu Shi
- Big Data Product Department, Wonders Information Co. Ltd., Shanghai, China
| | - Min Xia
- Department of Pediatrics, Renji Hospital, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Bo Ding
- Department of Pediatrics, South Campus, Renji Hospital, Shanghai Jiao Tong University, Shanghai, 201112, China
| | - Liling Qian
- Department of Respiratory Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Libo Wang
- Department of Respiratory Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Yonghao Gui
- Cardiovascular Center, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Xiaobo Zhang
- Department of Respiratory Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China.
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5
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Hogan AH, Carroll CL, Iverson MG, Hollenbach JP, Philips K, Saar K, Simoneau T, Sturm J, Vangala D, Flores G. Risk Factors for Pediatric Asthma Readmissions: A Systematic Review. J Pediatr 2021; 236:219-228.e11. [PMID: 33991541 DOI: 10.1016/j.jpeds.2021.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To systematically review the literature on pediatric asthma readmission risk factors. STUDY DESIGN We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk. RESULTS Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4). CONCLUSIONS Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions. TRIAL REGISTRATION CRD42018107601.
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Affiliation(s)
- Alexander H Hogan
- Division of Hospital Medicine, Connecticut Children's Medical Center, Hartford, CT; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT.
| | - Christopher L Carroll
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; Division of Critical Care, Connecticut Children's Medical Center, Hartford, CT
| | | | - Jessica P Hollenbach
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; Asthma Center, Connecticut Children's Medical Center, Hartford, CT
| | - Kaitlyn Philips
- Children's Hospital at Montefiore, Bronx, NY; Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Katarzyna Saar
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
| | - Tregony Simoneau
- Boston Children's Medical Center, Boston, MA; Department of Pediatrics, Harvard University, Cambridge, MA
| | - Jesse Sturm
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; Department of Emergency Medicine, Connecticut Children's Medical Center, Hartford, CT
| | - Divya Vangala
- Department of Pediatrics, Duke University, Durham, NC
| | - Glenn Flores
- Department of Pediatrics, University of Miami Miller School of Medicine, and Holtz Children's Hospital, Jackson Health System, Miami, FL
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6
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Graff DM, Stevenson MD, Berkenbosch JW. Safety of prolonged magnesium sulfate infusions during treatment for severe pediatric status asthmaticus. Pediatr Pulmonol 2019; 54:1941-1947. [PMID: 31478612 DOI: 10.1002/ppul.24499] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 07/31/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Magnesium sulfate (Mg) is one of several "second-tier" therapies for treating severe status asthmaticus. Pediatric reports primarily describe bolus use with limited data regarding prolonged infusions. We sought to describe the safety of prolonged Mg infusions during therapy of status asthmaticus in critically ill children. DESIGN Single center, retrospective study. SETTING Thirty-four-bed tertiary level medical/surgical/cardiac surgical pediatric intensive care unit. PATIENTS Pediatric patients 2 to 18 years of age admitted with status asthmaticus receiving Mg infusion for more than 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN FINDINGS A total of 154 children received Mg infusions for a median of 53.4 hours (interquartile range = 36.6-74.8). The most common adverse event (AE) was hypotension (48.1%), almost exclusively diastolic (94%), and was mostly limited to 1 blood pressure measurement (78%). 2.9% of events required intervention (fluids, decrease Mg infusion). Other AEs included nausea/emesis (22.7%), transient weakness (14.9%), and flushing (6.5%). Five patients experienced serious AEs including hypotonia (n = 1), escalation to continuous or bilevel positive airway pressure (n = 3), and sedation (n = 1), all attributed to progression of underlying medical disease. No patient required endotracheal intubation. Supratherapeutic levels (>6 mg/dL) were uncommon (2%) and were not more likely to be associated with AEs. Most (81%) patients were therapeutic by the 2nd Mg level check. CONCLUSION Prolonged Mg infusions were well tolerated in pediatric status asthmaticus patients. While diastolic hypotension was not uncommon, rarely were interventions deemed necessary. No serious AEs were attributed to Mg. Toxicity was uncommon suggesting that Mg levels could potentially be checked less frequently than historically reported.
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Affiliation(s)
- Danielle M Graff
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - Michelle D Stevenson
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville, Louisville, Kentucky
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Giangioppo S, Bijelic V, Barrowman N, Radhakrishnan D. Emergency department visit count: a practical tool to predict asthma hospitalization in children. J Asthma 2019; 57:1043-1052. [PMID: 31225968 DOI: 10.1080/02770903.2019.1635151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: Resource limitations and low rates of follow-up with primary care providers currently limit the impact of emergency department (ED)-based preventative strategies for children with asthma. A mechanism to recognize the children at highest risk of future hospitalization is needed to target comprehensive preventative interventions at discharge. The primary objective of this study was to determine whether frequency of ED visits predicts future asthma hospitalization in children.Methods: Children aged 2-16.99 years with asthma ED visits between 2012 and 2015 were identified through health administrative data. Survival analysis using Kaplan-Meier estimator and multivariable Cox regression models with time-varying covariates were used to quantify the number of ED visits in the previous year that would best predict hospitalization risk in the following year, after adjustment for age, sex, and presentation severity.Results: We identified 2669 patients with 3300 asthma ED visits. ED visit count was an independent predictor of future hospitalization risk (p < 0.001), demonstrating a dose-dependent response. Compared with zero previous visits, the adjusted hazard of future hospitalization in children with one visit or two or more visits was 2.9 (95% CI 1.6-5.0) and 4.4 (95% CI 1.9-10.4), respectively.Conclusions: ED visit count is a reliable predictor of future asthma hospitalization risk. Future studies could aim to validate these findings to support using ED visit count as a practical and objective tool to predict the children at the highest risk of future hospitalization and therefore, those who may benefit most from ED-based preventative interventions.
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Affiliation(s)
- Sandra Giangioppo
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Vid Bijelic
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Dhenuka Radhakrishnan
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
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Jean T, Yang SJ, Crawford WW, Takahashi SH, Sheikh J. Development of a pediatric asthma predictive index for hospitalization. Ann Allergy Asthma Immunol 2018; 122:283-288. [PMID: 30476547 DOI: 10.1016/j.anai.2018.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/31/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Variation in emergency department (ED) management for asthma exacerbation leads to disparities in care. Current asthma severity scores are insufficient to be used for hospitalization decisions. OBJECTIVE To develop and internally validate an asthma predictive index for hospitalization (APIH) to guide practitioners in their admission decision for children with asthma exacerbations. METHODS Data were collected from 12,066 children between 5 and 18 years old diagnosed with asthma exacerbation in the ED. Epidemiologic findings, number of inhaled corticosteroid canisters, short-acting β-blocker canisters, oral steroids, coexisting atopy, family history of atopy, insurance, and prior asthma ED visits or hospitalizations were compared between patients hospitalized and discharged. We used univariate analysis and multivariate analysis to determine the best predictor variables for hospitalization. Our study internally validated the prediction index to estimate future performance of the prediction rule. RESULTS The highest risk factors associated with asthma hospitalization from the ED are oxygen saturation less than 94%, respiratory rate greater than 31/min, history of pneumonia, and asthma ED visits in past 12 months. With a reduced predictive model that combined these risk factors, the odds ratio was 44.9 (95% CI, 32.8-61.4), which is extremely significant. Our C index of discrimination of 0.77 was similar to the validation C index of 0.78, which confirms a solid prediction model. CONCLUSION We have developed and internally validated a pediatric hospitalization prediction index for acute asthma exacerbation in the ED. Further studies are needed to externally validate the APIH before its implementation into clinical practice.
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Affiliation(s)
- Tiffany Jean
- Department of Allergy and Immunology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.
| | - Su-Jau Yang
- Department of Research and Evaluation, Kaiser Permanente, Los Angeles, California
| | - William W Crawford
- Department of Allergy and Immunology, Kaiser Permanente South Bay Medical Center, Harbor City, California
| | - Scott H Takahashi
- Department of Pediatric Ambulatory Care Pharmacy, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Javed Sheikh
- Department of Allergy and Immunology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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9
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Trivedi M, Patel J, Lessard D, Kremer T, Byatt N, Phipatanakul W, Pbert L, Goldberg R. School nurse asthma program reduces healthcare utilization in children with persistent asthma. J Asthma 2018; 55:1131-1137. [PMID: 29206057 PMCID: PMC5988937 DOI: 10.1080/02770903.2017.1396473] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/03/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We examined the impact of a novel, school nurse-supervised asthma therapy program on healthcare utilization. METHODS We retrospectively reviewed charts of 84 children enrolled in this program in central Massachusetts between 2012 and 2015. Physicians identified children with persistent asthma and poor medication adherence. These children were enrolled in the program to receive daily-inhaled corticosteroid at school, supervised by their school nurse, with ongoing communication between physician's office and school nurse through the school year. This program relied on established family, provider and school resources rather than research staff. The primary outcome was change in the number of emergency department (ED) visits in the year before and after enrollment. Secondary outcomes were hospital admissions, school absences, and rescue medication use. RESULTS The study population was on average 10.5 years old, 63% male, 67% Hispanic, 19% black, 14% white with 95% using Medicaid insurance. Asthma-related ED visits over a 1-year period decreased 37.5%, from a pre-intervention mean of 0.8 visits to a post-intervention mean of 0.3 visits (p < 0.001). Asthma-related hospital admissions decreased from a pre-intervention mean of 0.3 admissions to post-intervention mean of 0 admissions (p < 0.001). Asthma rescue medication refills decreased by 46.3% from the pre- to post-intervention period (p = <.001). There were also non-significant declines in school absences and oral steroid use for children enrolled. CONCLUSIONS We demonstrate a significant reduction in healthcare utilization for children enrolled in this unique school nurse-supervised asthma program, which utilizes a clinical-school partnership to deliver preventative asthma medication to school-aged children under sustainable conditions.
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Affiliation(s)
- Michelle Trivedi
- Division of Pediatric Pulmonology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Janki Patel
- Division of Pediatric Pulmonology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Darleen Lessard
- Division of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ted Kremer
- Division of Pediatric Pulmonology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Nancy Byatt
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Wanda Phipatanakul
- Division of Preventative and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Lori Pbert
- Division of Allergy and Immunology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Robert Goldberg
- Division of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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10
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Ardura-Garcia C, Stolbrink M, Zaidi S, Cooper PJ, Blakey JD. Predictors of repeated acute hospital attendance for asthma in children: A systematic review and meta-analysis. Pediatr Pulmonol 2018; 53:1179-1192. [PMID: 29870146 PMCID: PMC6175073 DOI: 10.1002/ppul.24068] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/15/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Asthma attacks are common and have significant physical, psychological, and financial consequences. Improving the assessment of a child's risk of subsequent asthma attacks could support front-line clinicians' decisions on augmenting chronic treatment or specialist referral. We aimed to identify predictors for emergency department (ED) or hospital readmission for asthma from the published literature. METHODS We searched MEDLINE, EMBASE, AMED, PsycINFO, and CINAHL with no language, location, or time restrictions. We retrieved observational studies and randomized controlled trials (RCT) assessing factors (personal and family history, and biomarkers) associated with the risk of ED re-attendance or hospital readmission for acute childhood asthma. RESULTS Three RCTs and 33 observational studies were included, 31 from Anglophone countries and none from Asia or Africa. There was an unclear or high risk of bias in 14 of the studies, including 2 of the RCTs. Previous history of emergency or hospital admissions for asthma, younger age, African-American ethnicity, and low socioeconomic status increased risk of subsequent ED and hospital readmissions for acute asthma. Female sex and concomitant allergic diseases also predicted hospital readmission. CONCLUSION Despite the global importance of this issue, there are relatively few high quality studies or studies from outside North America. Factors other than symptoms are associated with the risk of emergency re-attendance for acute asthma among children. Further research is required to better quantify the risk of future attacks and to assess the role of commonly used biomarkers.
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Affiliation(s)
| | | | - Seher Zaidi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Philip J Cooper
- Facultad de Ciencias Medicas, de la Salud y la Vida, Universidad Internacional del Ecuador, Quito, Ecuador.,Institute of Infection and Immunity, St George's University of London, London, UK
| | - John D Blakey
- Respiratory Medicine, Royal Liverpool Hospital, Liverpool, UK.,Health Services Research, Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
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11
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Buelo A, McLean S, Julious S, Flores-Kim J, Bush A, Henderson J, Paton JY, Sheikh A, Shields M, Pinnock H. At-risk children with asthma (ARC): a systematic review. Thorax 2018; 73:813-824. [PMID: 29871982 PMCID: PMC6109248 DOI: 10.1136/thoraxjnl-2017-210939] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 04/12/2018] [Accepted: 04/16/2018] [Indexed: 01/15/2023]
Abstract
Introduction Asthma attacks are responsible for considerable morbidity and may be fatal. We aimed to identify and weight risk factors for asthma attacks in children (5–12 years) in order to inform and prioritise care. Methods We systematically searched six databases (May 2016; updated with forward citations January 2017) with no language/date restrictions. Two reviewers independently selected studies for inclusion, assessed study quality and extracted data. Heterogeneity precluded meta-analysis. Weighting was undertaken by an Expert Panel who independently assessed each variable for degree of risk and confidence in the assessment (based on study quality and size, effect sizes, biological plausibility and consistency of results) and then achieved consensus by discussion. Assessments were finally presented, discussed and agreed at a multidisciplinary workshop. Results From 16 109 records, we included 68 papers (28 cohort; 4 case-control; 36 cross-sectional studies). Previous asthma attacks were associated with greatly increased risk of attack (ORs between 2.0 and 4.1). Persistent symptoms (ORs between 1.4 and 7.8) and poor access to care (ORs between 1.2 and 2.3) were associated with moderately/greatly increased risk. A moderately increased risk was associated with suboptimal drug regimen, comorbid atopic/allergic disease, African-American ethnicity (USA), poverty and vitamin D deficiency. Environmental tobacco smoke exposure, younger age, obesity and low parental education were associated with slightly increased risk. Discussion Assessment of the clinical and demographic features identified in this review may help clinicians to focus risk reduction management on the high-risk child. Population level factors may be used by health service planners and policymakers to target healthcare initiatives. Trial registration number CRD42016037464.
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Affiliation(s)
- Audrey Buelo
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Susannah McLean
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Steven Julious
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
| | - Javier Flores-Kim
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Andy Bush
- Department of Paediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, UK
| | - John Henderson
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - James Y Paton
- School of Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Michael Shields
- Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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12
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Teixeira S, Zuberi A. Neighborhood Social and Environmental Factors and Asthma Among Children Living in Low-Income Neighborhoods: The Importance of Informal Social Control. FAMILY & COMMUNITY HEALTH 2018; 41:214-224. [PMID: 30134336 DOI: 10.1097/fch.0000000000000202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Despite the knowledge that children in low-income neighborhoods are particularly vulnerable to asthma, few studies of child asthma focus on variation among low-income neighborhoods. We examined the relationship between child asthma and features associated with neighborhood poverty including safety, social cohesion, informal social control, collective efficacy, and disorder, across a sample of children from low-income neighborhoods (N = 3010; 2005-2007). Results show that the relationship between asthma and poverty is accounted for by family-level characteristics, but informal social control remains significantly and positively related to asthma after accounting for family-level characteristics. We discuss the importance of neighborhood environmental features for children's asthma.
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Affiliation(s)
- Samantha Teixeira
- School of Social Work, Boston College, Chestnut Hill, Massachusetts (Dr Teixeira); and Department of Sociology, Duquesne University, Pittsburgh, Pennsylvania (Dr Zuberi)
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13
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Abstract
UNLABELLED Preventable visits to the emergency department (ED) are estimated to represent as much as 56% of overall annual ED utilization and contribute to the high cost of health care in the United States. There are more than 25 million annual pediatric ED visits. OBJECTIVE The aim of this study was to identify factors associated with high ED utilization among children in vulnerable families. METHODS The Fragile Families and Child Wellbeing Study is a longitudinal cohort of approximately 5000 vulnerable children. Data from the 9-year follow-up survey were used in this analysis. Bivariate and multivariate logistic regression analyses were performed to identify correlates with high ED utilization (≥4 visits per year). RESULTS 2631 children were included in the analysis. In a multivariate model controlling for the child's sex, race, household income, and insurance status, 4 variables were significant predictors of ED utilization: history of hospitalization within the last year (odds ratio [OR], 15.97; 95% confidence interval [CI], 6.64-38.41; P < 0.001), diagnosis of asthma (OR, 2.53; 95% CI, 1.17-5.44; P = 0.02), number of child's office/clinic visits within the last year (OR, 1.22; 95% CI, 1.12-1.33; P < 0.001), and number of primary caregiver ED visits within last year (OR, 1.15; 95% CI, 1.03-1.28; P = 0.01). CONCLUSIONS History of hospitalization, outpatient visits, primary caregiver ED utilization, and diagnosis of asthma independently predict high ED utilization by 9-year-old children in fragile families. Augmented continuity of care, disease management, and caregiver education may reduce high ED utilization in this population.
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14
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Das LT, Abramson EL, Stone AE, Kondrich JE, Kern LM, Grinspan ZM. Predicting frequent emergency department visits among children with asthma using EHR data. Pediatr Pulmonol 2017; 52:880-890. [PMID: 28557381 DOI: 10.1002/ppul.23735] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/24/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE For children with asthma, emergency department (ED) visits are common, expensive, and often avoidable. Though several factors are associated with ED use (demographics, comorbidities, insurance, medications), its predictability using electronic health record (EHR) data is understudied. METHODS We used a retrospective cohort study design and EHR data from one center to examine the relationship of patient factors in 1 year (2013) and the likelihood of frequent ED use (≥2 visits) in the following year (2014), using bivariate and multivariable statistics. We applied and compared several machine-learning algorithms to predict frequent ED use, then selected a model based on accuracy, parsimony, and interpretability. RESULTS We identified 2691 children. In bivariate analyses, future frequent ED use was associated with demographics, co-morbidities, insurance status, medication history, and use of healthcare resources. Machine learning algorithms had very good AUC (area under the curve) values [0.66-0.87], though fair PPV (positive predictive value) [48-70%] and poor sensitivity [16-27%]. Our final multivariable logistic regression model contained two variables: insurance status and prior ED use. For publicly insured patients, the odds of frequent ED use were 3.1 [2.2-4.5] times that of privately insured patients. Publicly insured patients with 4+ ED visits and privately insured patients with 6+ ED visits in a year had ≥50% probability of frequent ED use the following year. The model had an AUC of 0.86, PPV of 56%, and sensitivity of 23%. CONCLUSION Among children with asthma, prior frequent ED use and insurance status strongly predict future ED use.
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Affiliation(s)
- Lala T Das
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Erika L Abramson
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York.,Department of Pediatrics, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York
| | - Anne E Stone
- Department of Pediatrics, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York
| | - Janienne E Kondrich
- Department of Pediatrics, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York
| | - Lisa M Kern
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Zachary M Grinspan
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York.,Department of Pediatrics, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York
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15
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Johnson LH, Beck AF, Kahn RS, Huang B, Ryan PH, Olano KK, Auger KA. Characteristics of Pediatric Emergency Revisits After an Asthma-Related Hospitalization. Ann Emerg Med 2017; 70:277-287. [PMID: 28302425 DOI: 10.1016/j.annemergmed.2017.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 12/15/2016] [Accepted: 01/10/2017] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We identify and characterize factors related to subsequent emergency revisits among children hospitalized for asthma. METHODS This population-based, prospective, observational cohort included children aged 2 to 16 years, hospitalized for asthma at an urban pediatric facility and followed for greater than or equal to 12 months. The primary outcome was asthma-related emergency revisit within 12 months of discharge. Revisits were identified by billing codes, respiratory chief complaints, and medications administered (eg, albuterol, systemic corticosteroids), dispensed, or prescribed. Predictors and covariates include demographic, socioeconomic, access, and environmental exposure variables collected during index admission. Multivariable logistic regression was used to evaluate the association between predictors and odds of asthma-related revisit. RESULTS A total of 671 children were enrolled; the majority were boys (65%), aged 4 to 11 years (59%), black (59%), and publicly insured (73%). There were 274 patients (41%) who were treated for asthma-related emergency revisits within 12 months of the index admission. In adjusted models, younger children, black children, children with excellent reported access to primary care, and children with a history of inhaled steroids were more likely to experience emergency revisits. Low income, detectable cotinine levels, and traffic exposure did not independently predict revisit. CONCLUSION Asthma-related emergency revisit is common after hospitalization, with more than 40% of children returning within 12 months. Socioeconomic and exposure-related risk factors typically predictive of asthma morbidity were not independently associated with emergency revisit among children in this cohort.
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Affiliation(s)
- Laurie H Johnson
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Andrew F Beck
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Robert S Kahn
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Patrick H Ryan
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kelly K Olano
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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16
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Hall AB, Novotny A, Bhisitkul DM, Melton J, Regan T, Leckie M. Association of emergency department albuterol dispensing with pediatric asthma revisits and readmissions. J Asthma 2016; 54:498-503. [PMID: 27715361 DOI: 10.1080/02770903.2016.1236942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Although pediatric asthma continues to be a highly studied disease, data to suggest clear strategies to decrease asthma related revisits or readmissions is lacking. The purpose of our study was to assess the effect of emergency department (ED) direct dispensing of beta-agonist metered dose inhalers on pediatric asthma ED revisit and readmission rates. METHODS We conducted a retrospective cohort study of pediatric patients discharged from the pediatric ED with a diagnosis of asthma. Our primary outcome measured the rate of asthma revisits to the ED or admissions to the hospital within 28 days. Logistic regression analysis was used to assess ED beta-agonist MDI dispensing and revisit and/or readmission as the outcome. RESULTS A total of 853 patients met eligibility for inclusion in the study, with 657 enrolled in the Baseline group and 196 enrolled in the ED-MDI group. The Baseline group experienced a revisit and readmission rate of 7.0% (46/657) versus 2.6% (5/196) in the ED-MDI group, (p = 0.026). ED direct dispensing of MDIs was found to be independently associated with a decreased risk of revisit or readmission (odds ratio 0.37; 95% confidence interval 0.14-0.95). CONCLUSIONS In our study, ED direct dispensing of beta-agonist MDIs resulted in a reduction in 28-day revisit and readmission to the hospital. Further studies should be performed to evaluate the economic impact of reducing these revisits and readmissions against the costs of maintaining a dispensing program. Our findings may support modification of asthma programs to include dispensing MDIs from the emergency department.
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Affiliation(s)
- A Brad Hall
- a Department of Emergency Medicine , Lakeland Regional Health , Lakeland , FL , USA
| | - April Novotny
- a Department of Emergency Medicine , Lakeland Regional Health , Lakeland , FL , USA
| | - Donna M Bhisitkul
- a Department of Emergency Medicine , Lakeland Regional Health , Lakeland , FL , USA
| | - James Melton
- a Department of Emergency Medicine , Lakeland Regional Health , Lakeland , FL , USA
| | - Tim Regan
- a Department of Emergency Medicine , Lakeland Regional Health , Lakeland , FL , USA
| | - Maureen Leckie
- a Department of Emergency Medicine , Lakeland Regional Health , Lakeland , FL , USA
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17
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Ram S, Zhang W, Williams M, Pengetnze Y. Predicting asthma-related emergency department visits using big data. IEEE J Biomed Health Inform 2015; 19:1216-23. [PMID: 25706935 DOI: 10.1109/jbhi.2015.2404829] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Asthma is one of the most prevalent and costly chronic conditions in the United States, which cannot be cured. However, accurate and timely surveillance data could allow for timely and targeted interventions at the community or individual level. Current national asthma disease surveillance systems can have data availability lags of up to two weeks. Rapid progress has been made in gathering nontraditional, digital information to perform disease surveillance. We introduce a novel method of using multiple data sources for predicting the number of asthma-related emergency department (ED) visits in a specific area. Twitter data, Google search interests, and environmental sensor data were collected for this purpose. Our preliminary findings show that our model can predict the number of asthma ED visits based on near-real-time environmental and social media data with approximately 70% precision. The results can be helpful for public health surveillance, ED preparedness, and targeted patient interventions.
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18
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Mismatch between asthma symptoms and spirometry: implications for managing asthma in children. J Pediatr 2014; 165:997-1002. [PMID: 25175496 DOI: 10.1016/j.jpeds.2014.07.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 06/18/2014] [Accepted: 07/11/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To examine the concordance between spirometry and asthma symptoms in assessing asthma severity and beginning therapy by the general pediatrician. STUDY DESIGN Between 2008 and 2012, spirometry testing was satisfactorily performed in 894 children (ages 5-19 years) whose asthma severity had been determined by their pediatrician using asthma guideline-based clinical criteria. Spirometry-determined asthma severity using national asthma guidelines and clinician-determined asthma severity were compared for concordance using weighted Kappa coefficients. RESULTS Thirty percent of participants had clinically determined intermittent asthma; 32%, 33%, and 5% had mild, moderate, and severe, persistent asthma, respectively. Increasing disease severity was associated with decreases in the forced expiratory volume in 1 second/forced vital capacity (FVC) ratio (P < .001), the forced expiratory volume in 1 second/FVC% predicted (P < .0001), and the FVC% predicted (P < .01). In 319 children (36%), clinically determined asthma severity was lower than spirometry-determined severity. Concordance was 0.16 (95% CI 0.10, 0.23), and when adjusted for bias and prevalence, was 0.20 (95% CI 0.17, 0.23). When accounting for age, sex, exposure to smoke, and insurance type, only spirometry-determined asthma severity was a significant predictor of agreement (P < .0001), with worse agreement as spirometry-determined severity increased. CONCLUSIONS Concordance between spirometry and asthma symptoms in determining asthma severity is low even when guideline-based clinical assessment tools are used. Because appropriate therapy reduces asthma morbidity and is guided by disease severity, results from spirometry testing could better guide pediatricians in determining appropriate therapy for their patients with asthma.
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19
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Abstract
Pediatric asthma is a disease that is managed across outpatient physicians, hospitalists, critical care physicians, and emergency department (ED) physicians. Scoring systems may facilitate a rapid assessment of the child with asthma in the ED. Short-acting beta agonists are still the mainstay of therapy for acute exacerbations along with corticosteroids and ipratropium bromide. ED providers must also know the indications for noninvasive ventilation and intubation. Most patients can be treated and discharged from the ED after acute exacerbation, and should be given a plan for going home that provides educational material and emergency scenarios to help prevent future acute incidents.
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20
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Shaw MR, Daratha KB, Odom-Maryon T, Bindler RC. Pediatric patients with asthma: a high-risk population for subsequent hospitalization. J Asthma 2013; 50:548-54. [PMID: 23544368 DOI: 10.3109/02770903.2013.790414] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Asthma is one of the most common chronic conditions among children and is one of the leading causes for pediatric hospitalizations. More evidence is needed to clarify the risks of repeat hospitalization and the underlying factors contributing to adverse health outcomes among pediatric patients hospitalized with asthma. The purpose of this study was to examine the risk of subsequent hospitalizations among pediatric patients hospitalized with asthma compared to a reference cohort of children hospitalized for all other diagnoses. METHODS The Washington State (WA) Comprehensive Hospital Abstract Reporting System (CHARS) was used to obtain data for the study. Data describing 81,946 hospitalized pediatric patients admitted from 2004 to 2008 were available. The risk of subsequent hospitalization among children admitted for asthma as compared to a reference cohort was examined. RESULTS The asthma cohort had a 33% (HR = 1.33 [99% confidence interval (CI) 1.21-1.46]; p < .001) increased risk of subsequent hospitalization from 2004 to 2008. Children in the asthma cohort under the age of 13 years demonstrated a significant increased risk of subsequent hospitalization as compared to the age-matched reference cohort of children without asthma. Those in the asthma cohort who were 3-5 years old demonstrated the highest risk (50%) of subsequent hospitalization (HR = 1.50 [99% CI 1.23-1.83]; p < .001). CONCLUSIONS Study results can be utilized in the development of appropriate interventions aimed at preventing and reducing hospital admissions, improving patient care, decreasing overall costs, and lessening complications among pediatric patients with asthma.
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Affiliation(s)
- Michele R Shaw
- College of Nursing, Washington State University, Spokane, WA 99210-1495, USA
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21
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Schuh S, Zemek R, Plint A, Black KJL, Freedman S, Porter R, Gouin S, Johnson DW. Practice patterns in asthma discharge pharmacotherapy in pediatric emergency departments: a pediatric emergency research Canada study. Acad Emerg Med 2012; 19:E1019-26. [PMID: 22978728 DOI: 10.1111/j.1553-2712.2012.01433.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma. METHODS This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed "comprehensive therapy," i.e., albuterol via metered dose inhaler (MDI) with oral and ICS. RESULTS The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p < 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and "intensive stabilization" (OR = 2.33, 95% CI = 1.29 to 2.67). Seventeen patients (2.6%) were prescribed antibiotics. Children were more likely to receive antibiotics if they had moderate to severe exacerbations (OR = 2.8) or received a chest radiograph (OR = 8.4). CONCLUSIONS The overwhelming majority of children discharged from Canadian pediatric EDs with acute asthma are prescribed inhaled albuterol via MDIs. Although the corticosteroid use at discharge is higher than previously reported, utilization of new prescriptions for ICS may not be optimal. Children presenting during daytime to EDs receiving intensive stabilization are more likely to receive the albuterol/oral steroid/ICS combination.
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Affiliation(s)
- Suzanne Schuh
- Department of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
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22
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Lovinsky S, Rastogi D. Prescription habits for preventative medications among pediatric emergency department physicians at an inner-city teaching hospital. J Asthma 2010; 47:1011-4. [PMID: 20868318 DOI: 10.1080/02770903.2010.491138] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION As asthma presentation is episodic, patients with acute exacerbations often present in the emergency department (ED) where preventative regimen may not always be addressed. Addressing initiation and modification of controller medications in the setting of an acute exacerbation may facilitate improved asthma control and decrease the frequency of ED visits, particularly so for families who receive most of their asthma management in the ED. However, this aspect has not yet been explored. METHODS We reviewed a random sample of 363 charts, 10% of the total number of asthmatic children, aged 2-18, seen from January to December 2007 in the pediatric ED of an urban teaching hospital located in Bronx, NY, USA. We quantified the frequency of modification of the preventative regimen and the influence of seasons on this practice. RESULTS Of these 363 children, 42.4% of patients were not previously on a controller medication. Of these, 9.7% were started on a new controller medication, with a significantly higher percent occurring in the summer months. Of those that were previously on a controller medication, 2.87% were started on a new controller medication and 0.95% had their controller medication dose increased. However, the regimen was not adjusted in 14.3% that had been seen four or more times in the preceding 2 years. Of the total 363 children, 78.5% were discharged from the ED on a short course of oral steroids, and this was not part of their preventative regimen. Only four charts had physician-documented asthma severity classification. CONCLUSIONS We found that the preventative regimen was modified in only 0.9-2% of all asthmatic children seen in an urban ED whereas 78.5% were started on systemic steroids. Asthma severity was evaluated in a very small number of patients. Because modification of preventative regimen requires appropriate asthma severity classification, the inclusion of asthma severity classification as part of routine ED evaluation may encourage physicians to address controller medications in persistent asthmatics.
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Affiliation(s)
- S Lovinsky
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Dombkowski KJ, Hassan F, Wasilevich EA, Clark SJ. Spirometry use among pediatric primary care physicians. Pediatrics 2010; 126:682-7. [PMID: 20819894 DOI: 10.1542/peds.2010-0362] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This study explores the use of spirometry in primary care settings. METHODS A 4-page survey was mailed to a national, random sample of office-based family physicians and pediatricians. Survey items addressed knowledge, attitudes, and practices regarding spirometry and standardized clinical vignettes. Data were analyzed by using χ2 tests and multivariate logistic regression. RESULTS Among the 360 respondents who provided care to children with asthma, 52% used spirometry in clinical practice, whereas 80% used peak flow meters and 10% used no lung function tests. Only 21% routinely used spirometry for all guideline-recommended clinical situations. More family physicians than pediatricians reported using spirometry (75% vs 35%; P<.0001), and family physicians were more comfortable in interpreting spirometric results (50% vs 25%; P<.0001). Only one-half of respondents interpreted correctly the spirometric results in a standardized clinical vignette, and the frequency of underrating asthma severity increased with the inclusion of spirometric results. The most common barriers to the use of spirometry, that is, time and training, were cited more often by physicians who did not use spirometry. Two-thirds of respondents agreed that they would want additional training regarding implementing spirometry in their clinical practices. CONCLUSIONS The use of spirometry in primary care settings for children with asthma does not conform to national guidelines. Widespread implementation of national asthma guidelines likely would require a major educational initiative to address deficiencies in spirometry interpretation and other barriers.
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Affiliation(s)
- Kevin J Dombkowski
- Child Health Evaluation and Research Unit, School of Medicine, University of Michigan, Department of Pediatrics and Communicable Diseases, Division of General Pediatrics, 300 N. Ingalls St, Ann Arbor, MI 48109-5456, USA.
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Abstract
PURPOSE OF REVIEW To report on recent advances in quality initiatives in emergency departments (EDs), with a special focus on applicability to pediatric EDs (PED) RECENT FINDINGS: Although healthcare quality improvement has made great strides in the last couple of decades, quality improvement efforts in pediatrics have lagged behind. Over the last decade, as quality initiatives have matured in adult hospitals, there has been a downstream effect on general EDs, as system-wide clinical guidelines are usually initiated through the ED--such efforts are being reported in the literature. There is significant overlap in quality improvement efforts in adult and pediatric EDs. In this article, we review the recent relevant articles, with particular emphasis on pediatrics where appropriate. SUMMARY There is an opportunity in pediatric emergency medicine to reduce practice variability, decrease cost and improve efficiency of care. There is an urgent need to report the successes and failures of these initiatives, so we can develop benchmarks and optimize services provided in the PED.
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